Friday, March 09, 2012

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.
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 <> 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.


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