Value Options, the Authorizing Company for Outpatient Mental Health Care in NC, Creates Barries for Citizens w/ Severe Persistent Mental Health Dx

Marsha V. Hammond, PhD Licensed Psychologist, NC
Billing address:
Cell: 828 ----------- e mail: Chomskysright@gmail.com

March 22, 2012

RE: the company Value Options (authorized by NC Medicaid) creating barriers for mental health care for NC citizens with SPMI (Severe Persistent Mental Illness) having Medicaid insurance

Dear Nelson Dollar, Chairman of Health & Human Services Committee and Member, Health and Human Services Subcommittee on Mental Health (307B1 Legislative Office Building; Phone: 919-715-0795Email:Nelson.Dollar@ncleg.net; Legislative Mailing Address:
NC House of Representatives300 N. Salisbury Street, Room 307B1 Raleigh, NC 27603-5925:

Thank you for reading this letter. I would like to bring to your attention problems I am experiencing w/ Value Options, the company who, for years, and until recently----- has been efficiently managing outpatient mental health service authorizations for NC Medicaid citizens having SPMI (Severe Persistent Mental Illness e.g., Schizophrenia; Schizoaffective Disorder, etc.).
As a pertinent point, commonly, citizens who experience symptoms associated with a diagnosis of schizophrenia benefit more from medication management rather than therapy and medication management. This is not true of people having ‘lesser’ diagnoses, if you will, that is, SPMI diagnoses such as Schizoaffective Disorder. There are quite a few diagnoses associated with the SPMI category. Mental health issues such as these are CHRONIC, like diabetes---and they don’t go away after two years----which is why Value Options has stated to me they are sending ‘for review’ my request for more than 8 outpatient therapy sessions for the client of which I am speaking here. Apparently, if you are not cured in two years, they balk at the continuation of outpatient mental health care for NC Medicaid citizens.
The DSM (the psychiatric manual which outlines mental health issues) outlines Schizoaffective Disorder in such a way that it is, to my thinking, ‘in the middle’ or on a continuum between Schizophrenia and Bipolar Disorder. In other words, it is something of a psychotic disorder and something of a mood disorder. Medications assist with the maintenance of the symptoms but do not make them go away.
More specific to this letter, I have a client who for 6 years has received weekly outpatient mental health therapy for 45 minutes/ visit who has benefited greatly from this therapy. His social skills are much improved; he is generally happier; he adheres to his medication; he is not paranoid when he goes into a store; he lives independently and manages his own affairs. Contrarily, he could live in a family care home, which would cost Medicaid many more thousands of dollars / year than living independently----a matter which I believe is made possible, in part, due to careful follow up by mental health providers in Haywood county.
When I met him, he had a knife in his pocket when he visited me. He has beaten a man almost to death. He still threatens to kill his father due to neglect he experienced as a child due to the father. He continues to experience auditory and visual hallucinations on a daily basis; he is intermittently depressed. He is followed by a psychiatrist and this is as good as he gets, basically.
NEVERTHELESS, today, a Value Options ‘case manager’, specifically, Mary (Value Options tel number: 1 888 510 1150, x 292604) has informed me that upon my submission of the ORF2 authorization request which has been approved for the past 6 years for outpatient mental health care, that for this man w/ SPMI, it is being referred to ‘a doctor’ and I will have waited for over two weeks to receive information as to whether I can be paid to continue to see my not infrequently homicidal client.
I think you can understand why I am concerned. I have an ethical obligation to continue to see him. It would be tragic if he acted on his homicidal ideations. He is able to call me late at night---which he does on a regular basis when he is depressed. He also calls the emergency hot-line in Haywood county. I consult with his Primary Care physician (the private company psychiatric nurse who carried an enormous patient load, has quit in Haywood county as has a psychiatrist due, I believe, to their work load) in order that his medications be continued.
Public mental health care is collapsing in western NC and we do not need more barriers being created by Value Options. We simply want to do our work and be paid by NC Medicaid. We do not need more paperwork and more phone calls from Value Options. We need to be able to efficiently do our work.
As associated with the neighboring LME, Western Highlands Network, there are over 80,000 Medicaid eligible patients. I have no idea how many there are for Smoky Mountain Center with its additional 7 counties (15 total counties for SMC LME). We are undoubtedly talking about at least 150,000 Medicaid eligibles and it is simply not tenable to have Value Options nickel and diming providers in this manner. Please, please address this issue.
As you perhaps know, there are 8 automatic outpatient mental health therapy sessions automatically available to NC citizens who have Medicaid insurance. After that point, Value Options must give authorization via the ORF2 form (in use for years, but now since October, 2011, must be filed electronically, a much more time consuming process) in order that the mental health provider be paid for his/ her work.
I wanted to advise you of the current difficulties I am experiencing from Value Options, as pertaining to this intermittently homicidal client in Haywood county, who is a Medicaid recipient, as associated with the creation of barriers to outpatient mental health care which has, in the past, greatly assisted this citizen. When I asked the Value Options ‘case manager’, Mary, today, if I should have checked the “3” as associated with the ORF2 form, as pertaining to ‘homidical tendencies’, she indicated that this would imply that the citizen is walking around with a gun and killing people. I do not believe that we want to go in that direction and that this citizen merits persistent follow-up and that Value Options needs to pay attention to the diagnostic categories of the NC citizens’ mental health diagnoses severity. Instead, I checked a ‘1’ but this was before our therapy session during which the client advised me that he wanted to ‘beat the brains out of my father.’ I advised Value Options of this matter. I found them most unhelpful.
Thank you again for reading this letter and I look forward to hearing from you. Please feel free to circulate this letter as you see fit.

Sincerely,

Marsha V. Hammond, PhD, Licensed Psychologist NC

Value Options, The Company That Authorizes Outpatient MH Visits Gives Providers a 'Beta Version' of the Demanded Authorization (old ORF2) Form

Gee, I used to spend about 30 minutes filling in 10 clients' worth of the ORF2 form which I faxed to Value Options in order to get authorizations to see my Medicaid patients and get paid.

Now, Value Options (going electronic, dontchaknow) has created a beta version of this one page simple form that goes on for 8 pages.

You go to the Value Options web page; Providers; Authorization (some such).

Here are some things to keep in mind:

1. most of the people you talk to at Value Options at the Clinical Authorization at 1 888 510 1150 will give you wrong information. You best stay on the phone the entire time you go thru this the first time tho they will say, "I can only stay on the call for 2 minutes." Be insistent. Plead mad and stupid.

2. If you have to get up and go see a client while it takes you 15 minutes to go thru the 8 pages, you better save it to the 'DRAFT' ---though one VO person stated "its supposed to save it automatically" (it doesn't).

3. Don't list any of the medications on page 6/ 8 pages where it looks like you should and where you would have given the old ORF2 form. The reason? If your client is taking a medication that is not in the drop-down box category, like Lunesta or Ambien, it will not let you get beyond page 6. No, it does not allow you to classify these hypnotic meds as "Other." The software has no idea what to do w/ that. Instead, contrary to what another person at VO stated, you include the med information in the "Narrative Box" which is on page 5 prior to the medications. Make sure you check "N/A" to all 4 medication boxes even though you have included in the Narrative Section the list of meds and the doses. And include information about whether the client is psychotic. Oops: I forgot to ask if I wrote in the Narrative Box "client experiences A/V/H" if anyone there would have any idea what that means. (Auditory/ Visual/ Hallucinations: standard vernacular for mental health practitioners).

4. If you have to back up and go to a previous page, don't use your back arrow as it will simply lose all the information. I don't know what you do in this case because if you re-enter the authorization form at page one----say you had to get up and actually do something other than paperwork------you have to refill in about half of the information on pages 1,2,3 again.

THANK YOU Value Options for giving the overworked and aggrieved mental health providers of NC the BETA VERSION of your software for which you have undoubtedly been paid handsomely.

Oh, and when you get to page 8, you get a red bold message that states that 'someone is going to look at the authorization and get back to you shortly.' What does that mean, I asked the poor VO woman who had on the phone for about 30 minutes: it means that it has been submitted and if they have any questions about the number of sessions they will call you.

Right. Don't forget to print off that authorization page because once you send in the authorization, you can no way, no how, get back to it. It does not get saved anywhere that the provider can look at it.



5.

8 Unmanaged Medicaid Therapy Visits Still in Place w/ Registration Form; Billing under Medicaid Waiver

I am thankful to say I found two helpful people at Western Highlands Network (WHN) LME this morning. Dorothy Sutton stated that there continue to be 8 unmanaged/ non-preauthorized psychotherapy visits prior to a need for authorization and massive paperwork re: the Medicaid Waiver.

The problem is in the billing. There is now no automatic way for your billing service----as in the past-----to link to Medicaid after Medicare has paid as the primary. I talked to Michael Beverage (yes, that's the correct spelling) beve0738@westernhighlands.org who is aware of the situation w/ the non-efficient cross-over. He suggested that my electronic biller speak with him (I wouldn't send those questions to billing@westernhighlands.org if I were you given how many people do not know what to do under the Medicaid Waiver).

More information as I gather it on this important matter.

WHN LME Advises Me I Can Continue to See My Medicaid Clients but no New Ones: NC Medicaid allows for 8 automatic therapy visits

I find it perplexing how it is that WHN LME Provider Network is stating that no new Medicaid patients can be admitted to a psychologist's practice when the rule as per NC DHHS, best I understand it, is that there are 8 automatic sessions authorized and after that authorizations have to be in place. This is the way it has been for years . Now, WHN LME is telling me that this is not possible.

Prior to even being allowed to continue to see my Medicaid clients and be paid, I was asked to list the clients---which I did----and to which Ms. Faulker below refers. She is telling me I cannot see any other Medicaid clients without prior authorization from WHN LME when WHN LME Board minutes from this past Friday indicate a Medicaid utilization rate of less than 5% in a catchment area in which there are over 80,000 Medicaid patients.

Here is my letter to Ms. Faulkner, Provider Relations WHN LME:

______________________________

Dear Ms. Faulkner:

Thank you for a response to my repeated inquiries. I know you are at least as busy as I am. I am sorry to cause difficulties as per your process and I mean this sincerely. There is enough suffering in the world.

I have several questions and I forward the to Arthur Carder, CEO as well as to Nettie Jones who is the Buncombe County representative on the WHN LME Board. Ms. Jones, whom I visited this past Saturday, at her home, related to all these difficulties, is being sent this in the US Mail.

First of all, in all past years, and as per your request that I, " Please do not admit any new WHN enrollees without prior approval from WHN" ,NC Medicaid patients have automatic authorization for 8 therapy sessions without prior authorization. What has happened to that? Has this been changed at the state level in terms of law? I ask this question sincerely.

Here is another related issue. As you know, many Medicaid clients are dually eligible which means that Medicare is their primary insurance and Medicaid is their secondary. I have been using a professional billing service for several years now and there has been efficient wrap-around----as it was intended to be, I believe-----with Medicare being billed first and then medicaid. My biller has stated to me that she does not know how this is going to take place since the Medicaid waiver was put into place.

In other words, the billing end of things is now non-transparent. And now you tell me that the authorization end of things is up for grabs in terms of there are no more 8 automatic sessions and then authorization is requested----previously a one page form efficiently handled by Value Options which took care of Medicaid authorizations.

What is the authorization procedure as per WHN LME please? I have someone asking me for services. I want to know, clearly, what has happened to the 8 automatic sessions under this Medicaid waiver environment.

As no private provider has been told, best I understand the matter, that there is a ceiling on the number of clients they can see, it seems to me obviously predjudiced that you believe you must apply this to this doctoral level, well-trained psychologist who sees people with serious mental health challenges.

This is not really helpful re: people needing services. That is why, I assume, the automatic 8 sessions was put into place some time ago. Mental Health needs are not like going to the ambulatory center in order to have your sprain ankle treated.

Thanks and have a nice day.
Sincerely,
Marsha V. Hammond, PhD.
__________________________________________________________

Here is a brief excerpt from Melissa Faulkner of Provider Relations of WHN LME for the purposes of clueing other providers that apparently, under the Medicaid Waiver, there are no 8 authomatic sessions for therapy-----as is mandated----best I understand it----under NC DHHS. I ASSUME that any other Medicaid provider would be told exactly the same information which makes it general information and in that it appears to be that, it should be posted at the WHN LME Provider site ( I have not looked for this, admittedly, but in that it seems to be a 'rule' WHN LME is creating re: the Medicaid waiver, I assume it must be there----somewhere):

"On Thu, Mar 8, 2012 at 5:30 PM, Melissa Faulkner <faul0852@westernhighlands.org> wrote:> March 8, 2012>> >> Marsha V. Hammond, PhD.>>

Dear Dr. Hammond:........... This application is intended to you allow you to serve the individuals indicated on the list you submitted on February 23, 2012. This application does not permit you to serve any additional enrollees of the WHN Network. Please do not admit any new WHN enrollees without prior approval from WHN....."
________________________________________________________
These are nothing but barriers being created to any mental health care as per the Medicaid Waiver environment at WHN LME. Mental health needs are frequently begun on an emergency basis----and not as associated with waiting for weeks for an authorization.

The Medicaid Waiver is Failing Miserably at the Level of Services and Costs to Taxpayers

Richard Craver who writes regularly on NC mental health issues, wrote the following article at the Winston-Salem Journal recently:

http://www2.journalnow.com/news/2012/mar/06/3/centerpoint-to-ask-for-153-million-from-forsyth-co-ar-2014773/#fbcomments

"UPDATE: CenterPoint to ask for $1.53 million from Forsyth County to help with Medicaid transition"

here is my comment placed after the article. You too could put your two cents in.

__________________________________________________________

THE MEDICAID WAIVER IS NOT WORKING IN TERMS OF SERVICES AND COSTS TO TAXPAYERS

Will this torture never stop? No, it will not stop until all these little companies---and that includes the LME's----are not scrambling for the various bits of Medicaid pocket change. Yes, that means CENTRALIZED administration and billing....like Medicare----with its administrative costs of around 5%. So, we're paying HOW MUCH to have the LME watch the transition of paperwork while the providers are waiting on their authorizations so they can see their patients so they can stay out of the hospital and save Medicaid money?

And the scrambling for the money has, of course, been part of the course as associated with being a provider, specifically, a clinical psychologist. I am still waiting 6 weeks later, to have the initial part of my application to CONTINUE to be a Medicaid provider as associated with the catchment area of WHN LME. I made a presentation to the WHN LME board this past Friday: no information. I call up the Provider Relations Department of WHN LME: no information. I have never been charged w/ a Medicaid violation; I have a spotless ethical record; I am a licensed psychologist. Then I have weeks after that to have the rest of my application reviewed WHEN I HAVE BEEN A MEDICAID PROVIDER WITH NO DIFFICULTIES FOR OVER 7 YEARS IN NC.

Mr. Craver, the reporter for this article outlined the purpose of the Medicaid Waiver which has now been hoisted onto Western Highlands Network (WHN) LME in western NC. This LME oversees 8 counties, mostly rural, with 80,000 Medicaid eligible patients and a less than 5% use of mental health $$ for the month of January, 2012, according to WHN LME recent board meeting graphs and information---handed out to the public March 2, 2012.

In the article, Mr. Craver stated: "The primary goal of the waiver program is to combine the management of Medicaid and state funds at the community level to reduce costs and add more accountability and consistency to behavioral-health reform."

If the LME cannot plan what monies it is going to need as per Mr. Craver's article----and they KNOW how many Medicaid eligible patients are associated with their LME S when they create projections for funding----then please give Medicaid back to the state where it was functioning perfectly well from this provider's perspective.

As for the state funded clients, specifically, those without any insurance---no Medicaid, no Medicare, nothing-----very few providers can or are willing to work with those patients due to the enormous paperwork challenges. I gave up years ago.

So, we have management entities, specifically the LME's like Centerpointe and Western Highlands Network LME who have the following problems under this Medicaid waiver:

1. they hold their hands out to the counties in a bait and switch maneuver after they have been granted the ability to supposedly manage Medicaid----which they obviously cannot do as described in the article....

2. they cannot process provider applications in a timely manner; they cannnot process paperwork for the companies rendering services to Medicaid clients----even with an expanded new set of hirees at the LME----thus causing Medicaid fraud to be committed----either that or the companies collapse....

3. due to the inefficiency of these two LME's or the fact that the providers are barred because they speak up, providers will continue to collapse and mental health care will continue to deteriorate under the Medicaid Waiver as the LME is not able or willing to continue to certify providers who have been working w/ Medicaid patients for years.....

4. As associated with the Medicaid waiver and how it was created by Piedmont Behavioral Health, the LME's, including WHN LME Board were required to sign a non-disclosure agreement which disallows Medicaid clients and providers from obtaining any information about what has happened, for instance, to their provider application----with no calls returned. The WHN LME attorney told the WHN LME CEO who told the chair of the Board that 'there has to be a '100% positive vote on this Medicaid waiver' last June, 2011......another piece of arm-twisting.....

So, you have a public health entity, specifically, the LME's, under this Medicaid Waiver, otherwise known as The Borg (see Startreck, the Second Generation) which beg for additional monies, cannot manage their money, cannot manage their paperwork at practically any level for any sustained period of time, who allow providers to see less than 5% of the Medicaid clients in a population of patients that research would indicate have a lot of mental health challenges due to: poverty; lack of jobs; poor education; poor transportation.

This Medicaid waiver is not working. And its not going to work because of the way it was set up which is completely interwoven with non-transparency,arm-twisting, lethary, inefficiency, LME's heavy w/ administration costs and no direct patient care, and not least, cronyism. It is the worst of all possible worlds.

I called Western Highlands Network LME this past week, indicating that I had a suicidal Medicaid client: they told me to have the client call the hotline. The person there said she had 'nothing to do w/ the provider network end of things.' So, add lack of communication within the LME to the long list of what the LME's are not able to do under this Medicaid waiver.

Marsha V. Hammond, PhDLicensed Psychologist, Asheville, NC Mental Health Reform blogspot: http://madame-defarge.blogspot.com/

Soliciting Contact w/ the Federal Centers for Medicare & Medicaid Services (CMS) re: Inability to Be Paid to Work w/ Medicaid clients under WHN LME

Marsha V. Hammond, PhD Clinical / Health Psychology NC Licensed Psychologistcell: 828 ---------e mail: chomskysright@gmail.com NC Mental Health Reform blogspot, since 2007:http://madame-defarge.blogspot.com/

March 7, 2012

Dear Dr. Diane Pedulla of the American Psychological Association Practice Directorate:

I left a message for you today. Thank you for your hard work re: psychologists in the US.

First of all, there is no point in me contacting the NC Psychological Association as they pay no attention to Medicaid matters in NC. I have joined twice and resigned twice over the past 10 years re: inability to engage them on these important public mental health care matters.

I am contacting you because although I have been a Medicaid provider in NC for the past 7 + years, I am being denied the ability to continue to do this under the Medicaid waiver that is wrecking Medicaid in NC. I am given no reason; I get no calls back from the Provider Network of the local LME/ MCO which is managing mental health care for Medicaid clients in western NC, specifically, Western Highlands Network (WHN) LME. This puts me in a clear ethical dilemma as my therapeutic relationships are long-term and with seriously mentally ill clients.

Here is the issue grossly outlined and more detail information is at my blog as listed above. NC has been undergoing a very, very challenging mental health reform over the past 12 years. It has not gone well; it has decimated the public mental health care system. The original design was two-fold: 1. to privatize mental health care, including Medicaid, so that there would be 'competition' which would diminish the $$ spent 2. to allow choice for patients regarding health care providers.
First of all, this is a very poor way to make money; competition does not work well within a system in which there is little money to be made and that includes Medicaid which is associated with impoverished clients with significant mental health challenges. Secondly, there is less and less choice as providers are collapsing from the duress related to NC mental health reform. Thirdly, the co-chairs of the legislative oversight committee, a free-standing committee, have completely changed members since Republicans took over the NC State Legislature. Thus, there is no continuity re: what has happened and where we were headed.

This is all related to a Medicaid Waiver which was hoisted onto the local LME/ MCO, specifically Western Highlands Network (WHN) LME/ MCO---the old community mental health center which for the past 7 + years has functioned as an administrative only entity. The LME/ MCO which created the Medicaid wavier, in eastern NC, far across the state, is Piedmont Behavioral Health (PBH LME/ MCO). The PBH LME/ MCO is leading the charge, if you will, across NC, re: this Medicaid waiver which appears to be a clear attempt of NC DHHS to rid itself of monitoring Medicaid----a federally mandated service. This Medicaid waiver includes a non-disclosure agreement which was basically a hostile take-over of the WHN LME Board which was signed, under duress, by the WHN LME/ MCO Board in June, 2011.

Prior to this Medicaid waiver, many companies and providers collapsed, including the loss of a major company under WHN LME about 7 years ago which covered 10,000 lives. WHN LME/ MCO now oversees 80,000 Medicaid eligible patients and in January, 2012, less than 5% of those patients received any mental health services. There is thus a very significant attempt to curtail Medicaid services utilizing the non-use of mental health providers, including psychologists.

There is no reason given to me by the Provider Network of WHN LME/ MCO as re: denying my continuing to provider Medicaid services. I have never had a charge leveled at me; I have no ethical violations; I have not been accused of Medicaid fraud. I do have my mental health care reform blog which has documented many injustices associated with Medicaid services over the past 7 years.

Moreover, I am advised by NC DHHS psychologist Bert Bennett, PhD that the LME/ MCO must allow in-place mental health Medicaid providers at least one year during which the LME/ MCO may evaluate who it wants to continue to allow to see Medicaid patients. I have presented these issues to the WHN LME Board, called dozens of times the Network Provider people at WHN LME/ MCO. I receive no information back. I have seriously mentally ill clients and I take seriously my therapeutic relationships with them.

Medicaid is a federal/ state joint enterprise, as I understand it. It is sustained by public tax dollars. I do not understand how such an arrangement allows a health care maintenance organization, in this case, the LME/ MCO, to decide, on the basis of comraderie with the LME/ MCO----as to who it will allow to be paid to see tax-payer supported patient care.

My query here is thus: given the importance of this matter re: Medicaid services, and given the useful track record APA has associated w/ working with CMS (Centers for Medicaid and Medicare Services), who can I speak to at CMS in order to bring forward these difficulties as associated with federal tax dollars associated health care?

I thank you in advance for your assistance and direction, Dr. Pedulla.

Sincerely, Marsha V. Hammond, PhD

Letter to NC Comm Co-Chairs:WHN LME Medicaid Providers Being Denied Access to Medicaid Authorizations: URGENT

The following letter was just sent to the 3 co-chairs of the oversight committee which pertains to Mental Health, Developmental Disability, and Substance Abuse Services in NC: Marsha V. Hammond, PhD Clinical / Health Psychology NC Licensed Psychologist cell: 828 772 1127 e mail: chomskysright@gmail.com NC Mental Health Reform blogspot: http://madame-defarge.blogspot.com/ March 6, 2012 Dear NC State Legislators who are Co-Chairs for the Joint Legislative Oversight Committee for Mental Health, Developmental Disabilities and Substance Abuse: Justin Burr; Nelson Dollar; and, Louis Pate I have been a Medicaid provider for over 7 years. I am a NC doctoral level Licensed Psychologist. I have severely mentally ill clients who go in and out of the psychiatric hospital. I am not able to get Western Highlands Network (WHN) LME to move forward my Medicaid provider application which is being required since WHN LME Board adopted the Medicaid Waiver from Piedmont Behavioral Health (PBH). Either its the Medicaid waiver that is wrecking the Medicaid system here, or the incompetency of WHN LME is wrecking it, or PBH telling WHN LME what to do (WHN LME was required to sign a non-disclosure statement). THERE ARE 80,000 MEDICAID ELIGIBLE PATIENTS UNDER WHN LME. Three thousand were served in January, 2012, according to hand-outs given to the public at the WHN LME Board meeting this past Friday. Prior to this, there were no issues for me and other Medicaid providers. I am now receiving information from other providers, including medical providers, who cannot bill and therefore see their patients re: this Medicaid waiver. I would like to know what you can immediately do about this matter. I cannot get calls back from the Provider Relations department. I went to the WHN LME Board meeting this past Friday, presented the issue, was given no solution. This is a very urgent matter. Thank you for researching this matter. Marsha V. Hammond, PhD, Licensed Psychologist, NC __________________________________________ These are the current members of the Joint Legislative Oversight Committee for Mental Health, Developmental Disabilities, and Substance Abuse NORTH CAROLINA GENERAL ASSEMBLY Raleigh, North Carolina 27601 Members Co-Chairs Rep. Justin P. Burr (Co-Chair) House Appointment Justin.Burr@ncleg.net Rep. Nelson Dollar (Co-Chair) House Appointment Nelson.Dollar@ncleg.net Sen. Louis Pate (Co-Chair) Senate Appointment Louis.Pate@ncleg.net Legislative Members Rep. Martha B. Alexander House Appointment Rep. William D. Brisson House Appointment Rep. William A. Current, Sr. House Appointment Rep. Mark W. Hollo House Appointment Rep. Pat B. Hurley House Appointment Rep. Bert Jones House Appointment Rep. Marian N. McLawhorn House Appointment Rep. Tom Murry House Appointment Rep. Fred F. Steen, II House Appointment Sen. Austin M. Allran Senate Appointment Sen. Doug Berger Senate Appointment Sen. Stan Bingham Senate Appointment Sen. Harris Blake Senate Appointment Sen. Jim Davis Senate Appointment Sen. Fletcher L. Hartsell, Jr. Senate Appointment Sen. Eric Mansfield Senate Appointment Sen. Martin L. Nesbitt, Jr. Senate Appointment Sen. William R. Purcell Senate Appointment Sen. Tommy Tucker Senate Appointment Advisory Members Hon. James Summers Forrester Senate Appointment

February Board Minutes of Western Highlands Network as Pertaining to Piedmont Behavioral Health (PBH) Who Created Medicaid Waiver

I woke up this morning and Henry Thoreau and Mose Allyson were beckoning to me. After sitting in that WHN LME Board meeting (part of it; I was too tired of everything there to stay to the part where they talked about the "Medicaid Waiver" associated w/ PBH), I had a troubled sleep. Its as if part of my unconscious was poking me, trying to say?....

Naw, that doesn't have anything to do with this blog flipping up on the first internet page most everytime I put "WHN LME" in the title.......

I put Mose on immediately and in particular one side of the record: "If You Only Knew." I looked the lyrics up on the web.

The first tragic thing was that everything on the web seemed to indicated that Van Morrison wrote it which is not true according to the sleeve of the record----so there's terrible irony in realizing that Mose knew even that he would not be credited with his song-writing of a song that tries to tip off the hip to the fact that they will forever be trying to get the real story (Mose is down there on page 1 of the web, however...just not at the top):

"....If you only knew all the dealing
That goes on in back of the store.
If you only knew how that one that's
Got a lot can't wait to get more.
I wouldn't want to cramp your style
But if you want to make it all worthwhile.
You have to have your own breakthrough.
If you only knew.

If you only knew what could happen to
A man for telling the truth.
If you only knew all the scruples
That go down in gin and vermouth.
I wouldn't want to steer you wrong
But if you want to sing your own song.
Your gonna have to lose a few.
If you only knew."

So, speaking of all the dealing that unfortunately goes on at the back of the store, I looked at the February 3, 2012 WHN Board minutes (odd: there's no WHN Board minutes online after November, 2011) , specifically, the Chief Executive Officer Report. It clandestinely states (the person who creates the minutes got some training on tip-toeing around red flag issues): AHEM: The Edict:announcing horns please:

"......It has been decided by the State that PBH will take over two (2) LME's which will add another ) seven to eight (7-8) counties to their catchment area. (Why the quibbling here? There are exactly 8---no more, no less----counties associated with WHN LME). Mr. Carder was asked to be a part of the Oversight Committee on February 14, and he will let the Board know how it went at the next meeting. (Ohhhhhhh...)

Mr. Carder then addressed the issue of the PBH Non-Disclosure agreement. He wanted to ensure that people hav ea clear understand (sic) of why WHN is requiring people to sign that agreement. The process was created AFTER (bold italics in original) the implementation of the PBH Waiver five years ago, which is why PBH did not require their providers, community advisory council members, etc (I am reminded of Yule Brenner in the musical saying cavalierly: etcetera, etcetera, etcetera) to sign one. He took questions from the Board and other members of the public who were at the meeting. ..."

Ok, listen up all you etceteras:

I have no idea what that last paragraph just said and I can only assume that we're hiding things in this kind of talk. You may ask---- actually, I ask: just what is this PBH Non-Disclosure Agreement.

Who, besides the etceteras, have to sign it? Do client/ consumers sign it? Do providers offering current Medicaid services sign it? Do private companies sign it? Remember: the UNC Chapel Hill attorney stating that this waiver was going to shred the public documents

So, I search-engined "Piedmont Behavioral Health Non-Disclosure Agreement."

That was no help: only Madame Defarge posts show up. That and David Cornwall's NC Hope postings.

The language by, assumeably, Mr. Carder, is a carbon copy of David Cornwall's report (see: http://ncmentalhope.org/commentary/2011/compliance/) on PBH fooh-foohing the court system about why they did not provide treatment for a developmentally disabled person over there in eastern NC:

"....On April 5, PBH filed an objection that the court lacked jurisdiction since the issue of services was BEFORE (my caps) the state’s Office of Adminstrative Hearings. It further noted that Hummel was out of the country, that Baker was no longer employed by PBH, that the agency had no clincical director, and that there were no treating psychiatrists familiar with the case on PBH staff."

Not to worry, Mr. Carder of WHN LME: we understand that the signatures of the etceteras does not matter because the 'process was created AFTER the implementation of the PBH Waiver five years ago...."

Right.

In fact, the only information I can turn up on the web (I begin to see why the WHN LME attorney kept trying to shut me up yesterday) is associated with me copying what Mr. Carder (boy, I bet he regrets this) handed out at the WHN LME board meeting last June which is a statement from the UNC Chapel Hill professor re: just how the Non disclosure agreement would shred the public records law. And I posted it to David Cornwall's NC Hope pages and here it is, as well as in Defarge (otherwise, it does not exist):

"My understanding is that the information PBH intends to share with other LME’s includes written (in paper or electronic form) policies and procedures, manuals, forms, contracts, privileging and credentialing tools, provider standards, provider appeal processes and forms, consumer appeal process and forms, etc. The North Carolina Public Records Act permits public access to all public records in an agency’s possession unles the agency or the record is specifically exempts from the statute. (I will presume, here, that no one takes the view that PBH is not a governmental agency subject tot he public records statute. If I am wrong on this point, and need to address this qustion, please let me know). I have identified no provision of state law that explicitly exempts the PBH records at issue here from public access under the public records law. The public records act exemption for trade secrets does not apply, as that exemption applies to a trade secret that is the property of a private person."

What do you bet that if I employ the public records law to get my records associated with applying as a provider to WHN LME that they will utilize this Non-Disclosure Agreement to try and block me?

I'm dying to find out.

WHN LME Graphs for January, 2012 Medicaid Services

Today, at the WHN LME Board meeting, along w/ last month's minutes, which are, I believe, available on line, were two pages of graphs. I do not know if the graphs are available at the LME site.

Boy, are they misleading until you study them---even when you study them. The way the x-axes are numbered makes it look like a lot of people are getting services but across all the counties there is a mean of about 3.2% "Penetration Rate."

3.2%. That's how much of the Medicaid population is receiving any mental health services at all. That's astounding in a population that is impoverished, without resources, jobless or with low paying jobs, no childcare, and no transportation in mostly rural western NC.

These are the titles of the 6 graphs:

"Number Medicaid Eligibles"
"Number Served"
"Penetration Rate"
"Number of Persons Served by Total Funding"
"Number of Persons Served by State Funding"

And what does 'Number Served' mean? Does it mean someone called the LME? Does it mean a provider was reimbursed? What does it mean?

The "Number Medicaid Eligibles" for the 8 counties associated w/ WHN LME is over 80,000 people.

The "Number Served" in January, 2012 for mental health services of any kind, associated w/ Medicaid was less than 3000 people.

What's the difference between the two categories as above of "Number Served" and "Number Persons Served by Total Funding"?

Is the latter the dually eligible clients ? Most Medicaid clients are dually eligible. That means that they have Medicare as primary and Medicaid as secondary. Is the category "Number Persons Served by Total Funding" associated with the dually eligible clients given that there's about 30% more people in that category versus the "Number Served"?

Given that I cannot get any information about my Medicaid provider application from WHN LME, I don't hold out any hopes that I will get answers to these questions. I'll either have to bring it up at the next board meeting or try NC DHHS. Maybe Verla Insko (D-Orange county) who used to be the co-chair of the Joint legislative Oversight Committee for Mental Health Reform would know.

Does anyone know? Why are there no explanations for what the titles refer to?

Are these standard graphs across the LME's? If not, why not? There's no ability to compare if these are not standardized across the LME's. I have a sinking feeling that the LME's simply create graphs that make them look good. However, there's nothing good about these WHN LME graphs. It paints a picture of an LME that is heavily administratively funded doing not much of anything except pushing paperwork and blocking providers.

So, we've got millions of $$ being handed to LME's that basically coordinate the care for a very little number of the insured they are supposed to pay attention to.

My Questions to the Western Highlands Network LME Board This Morning and WHAT THEY DID and How They Responded

The below was stated at the Western Highlands Network (WHN) LME Board meeting today, March 2, 2012. It was recorded by hard-working citizen Jerry who selflessly records, on his own dime, every single Buncbome County official meeting-----be it the School Board or the City Council, or the LME. I imagine that recording could be you-tubed with some translating.

This past week, about 5 days ago, I asked CEO Arthur Carder's secretary if I could use an MP4 player to record this meeting----as does citizen Jerry (he has a tiny set-up, goddess bless him). Surprise: I didn't get an answer and today when I saw her (she is a nice woman) she indicated that Mr. Carder had not gotten back w/ her. Gee, I wonder why?

Today, when I addressed the board in my allotted 5 minutes, the Board's attorney cut me off at exactly 5 minutes. Bear in mind that there are some helpful people on the WHN LME Board. So, one of them, good soul, asked if I could not finish what I was saying. I finished my last paragraph.

The attorney interrupted me earlier when I mentioned a name that he obviously is unfortunately not familiar with, specifically, Vicki Smith, Executive Director of NC Disability Rights. He doesn't wait to interrupt: he just butts in, lawyer-style. (Hi, there, you reading this blog)

Uh, well, Vicki Smith is not employed by WHN LME, Mr. WHN LME Board attorney, I more or less said.

"Well, we can't be pulling up personnel issues", he said.

Uh,I wasn't pulling up personnel issues. I was simply describing how I could not get any response from Provider Relations and asking the Board to help me out here.

This is what I said and it should be you-tubed---not because I am someone special but because I am just oe little indication of the problems here. A lot of members of the board looked sad as I talked. Remember: this is more or less the same board that kicked dirt up in the air prior to being taken over by The Borg, oh, excuse me, Piedmont Behavioral Health (PBH)'s Medicaid waiver.

The board's attorney at that time practically shoved them into the pit mid 2011 (see Defarge blog on this re: "I think to be in a witness protection program). Same attorney, yep.

After the CFAC (family advisory council much-nicer-than-me) lady presented her spiel, another good soul on the Board who was last year the Chairman asked if they could not convene away from the prying eye of citizen Jerry's recording device. It was a secret meeting and I can understand why they do this and that they do it not infrequently.

However, when can I get an answer back to what is going on re: my 'request to send in an application' to the WHN LME Provider Relations?

Citizen Jerry suggested the information could be opened up after the meeting, or next month, or next year.

Great. This is what I said, more or less today ("shoot me if I play too long" said Steely Dan):

"I am Marsha Hammond, PhD, first Licensed as a Psychologist in 1995. For the past 7 years I have worked with NC DHHS, seeing Medicaid clients . The authorizations were organized, easy to obtain from NC Medicaid and the payment was efficient and simple. There was no paperwork on my end except for the once/ year, one page authorization form. In addition to my professional work, since 2007 I have maintained a blog under the moniker Madame Defarge , outlining mental health care issues in western NC. This makes me distinctly a challenge to the local LME’s.

In 2011, WHN ‘s Board decided to utilize the PBH waiver, thus declaring to current Medicaid providers the need for paperwork submission. It did not matter that I was already a Medicaid provider; it did not matter that I had submitted a similar set of paperwork several years ago to work with WHN state funded clients. I admittedly did not find the time to submit the paperwork prior to the January 3, 2012 deadline.

Then, when I did my Medicaid billing in January, 2012, I was reminded of the necessity of doing this. I initially contacted WHN Provider Relations Department Thursday, 5 weeks ago. 7 calls that day to Provider Relations, culminating in a call to Arthur Carder’s secretary to get a response finally outlined for me that I had to fill out a face page that was not easy to find on the WHN webpage. I turned it in the next day.

A week later I called Provider Relations several times to see what the next step was. I was then asked to turn in paperwork not connected to being a provider but a pre-step re: that process. The paperwork demanded was: my current tax return; a statement of what services I offered; a list of my clients; their Medicaid numbers; the date I had started seeing them; an attestation as to my availability. All this was turned in within one week.

After about 5 calls to Provider Relations, the director indicated to me that I was in a line with ‘2 other similar cases’ and was being considered ’in the order in which they are received.’ I have heard nothing. I have continued to call WHN Provider Relations. I ask that the Board obtain an answer to what is the next step as I cannot pry the answer out of Provider Relations.

As a bit of connected history, in 2006,under the WHN LME catchment area,the newly established private mental health care company, New Vistas/ Mountain Laurel collapsed suddenly; it had 10,000 mental health patients associated with it. WHN LME was left to pick up the pieces.

In 2011, New River LME was accused by SMC LME of ‘Medicaid fraud’ which was never fully explained anywhere in the press. Smoky Mountain Center (SMC) LME (who you can bet has its eye on WHN LME screwing up) did a hostile take-over of that LME.

Currently, as related to either paperwork chaos reigning at WHN and/ or the paperwork load demanded by WHN LME, there are private companies here that commit Medicaid fraud every working day. I have it from the horse’s mouth. I do not work for any agency. I am a solo provider.

The explanation from them is that ‘we have to make the money’ and it was outlined to me that the paperwork demands and short-deadlines----created by WHN in order to stay on top of Medicaid expenditures, I assume----is what is drowning the companies. Will the lack of paperwork efficiency create another collapse when this Medicaid fraud is discovered, if it is discovered?

When I asked Vicki Smith, ("whoa, stop right there, said the WHN LME Board attorney: see above) Executive Director of NC Disability Rights in Raleigh what she knew about the LME closing its provider network, as I queried her as to whether the PBH Support Needs Matrix, developed by PBH, was being used to exclude current Medicaid providers at WHN, she informed me that the LME’s who have signed on to the waiver are obligated to maintain “fidelity” to the PBH model. Upon asking her if PBH’s Support Needs Matrix, not dissimilar to other rubrics or a matrix that have been used in the past in order to obtain state funded client services---did she think that this Support Needs Matrix was possibly being utilized to limit mental health care. I am concerned about this due to the question that the WHN LME Provider Relations Department asked me, specifically, 'what services do you offer. Vicki Smith indicated that this Matrix has been determined to be used w/ the (primary diagnosis) DD population. So, it appears that WHN LME is not using this matrix in order to rule out the use of Medicaid monies for people with a primary Mentalo Health (MH) diagnosis (god help the DD population).

When I asked Dr. Bert Bennett of the Behavioral Health Unit of NC DHHS about whether WHN had closed its Medicaid provider network, he told me that WHN is expected to keep its doors open to all current Medicaid providers for at least one year; “During that year, the LME/MCO has the ability to evaluate thecapacity of their network and, after a year, they do have the ability to choose which providers will be in their network.”

I would like to know what is going on related to this current Medicaid provider’s WHN application to continue to provider Medicaid services in this catchment area. Thank you."

I am sorry to put you on the hot seat, Vicki Smith and Bert Bennett, but I simply want to know what is going on re: continuing to be a Medicaid provider----what I have been doing for years---re the Provider Relations Department at WHN LME.