Saturday, July 28, 2012

Guillotine Roll Call Time: CEO of WHN LME Loses His Position Due to $3 Million Shortfall Which the Chief Financial Officer Feigned Not Knowing About

This is my reply to the good article outlining what just took place today at WHN LME regarding the replacement of the CEO, Arthur Carder, who has been in his position, if I am not mistaken, for about 12 years.  Here is that article URL:


HEAD ROLLING TIME: Ask not for Whom the Guillotine Chops

Peggy Manning: you did a good job of providing the basic information.  However, God, or the devil, is in the details.  While it is important to have included the Mercer audit which was done July 23, 2012 (wonder who tipped off that independent auditor as to why they should take a look at the WHN LME records?), its very difficult to understand even for someone who has been studying NC mental health reform for years now----and blogged about minute details.

The Director of Clinical Operations of WHN LME stated these to be the problems which caused the $3 million overspending: "(1) an encumbrance with contractual obligations inherited from former managed-care agencies Value Options and Crossroads;(2) increases in the cost for some services; (3) and the lengthy duration of some services meant to be short-term in conjunction with service stacking."

As regards No 1, for outpatient therapy, which is what this psychologist does,  'the Medicaid year' starts 1.1. (whatever year).  After 8 outpatient therapy sessions, authorization must be approved for more sessions.  Moreover, I imagine that outpatient therapy, which SHOULD be the work-horse of mental health care, devoured very little of the LME's money.

As a doctoral level psychologist, for a 45-50 minute session which is what they mostly will approve you for, I get paid about $75.  I have Medicaid clients that I see weekly (not as associated w/ WHN LME) and even at that frequency, that would be $3700/ year.  Moreover, outpatient therapy for these kinds of SPMI (Severe Persistent Mental Illness) clients would encompass psychosocial aspects which bear a closer resemblance to social work e.g., assistance w/ finding jobs, transportation, etc., that the way that one usually thinks of as therapy.

It is an unusual Medicaid patient that receives this weekly outpatient therapy.  Moreover, most patients who are disabled, have Medicare as primary, which pays significantly better than Medicaid, and Medicaid simply picks up some pocket change. Medicaid is the payer 'of last resort.'

So, when the Clinical Director is talking about 'encumbrances inherited' I have no idea what she is talking about.  WHN LME knows very well how difficult it is to obtain authorizations for any service, including the expanded services such as PSR or Psychosocial Rehabilitation.  This is a modality offered by the private companies which were created when NC started mental health reform in 2002 that includes DAILY 6 HOUR classes intended to teach social skills, etc.  Also as associated with those private companies there are therapy charges (I refer to the 'stacking' matter which the Clinical Director indicates in No 3 is sucking down the bucks), etc.

As re: No 2, I certainly have not received any pay increase from Medicaid so I don't know what that's about either.

As re: No 3, the LME authorizes the duration of services and if they believe that there should be a cut-off point, then they could have limited the services.  But then----using the example of Psychosocial Rehabilitation offered by the private companies-----it is typical for clients to stay in PSR, for instance, for months and months.

There is background information to all of this as associated with the treatment of mental health challenges: are these people to be REHABILITATED or do they have CHRONIC ILLNESSES, like diabetes or hypertension.  When it comes to the SPMI population, their trajectory follows one associated w/  a chronic illness----not something that is going to get thorough treatment, like cancer, and then go away.  Nevertheless, the entire push / thinking behind much of what NC DHHS has put forward is associated with REHABILITATION.

So, you have intensive services meant to rehabilitate someone when  in fact, the 'cure' as much as is possible, is slow, takes place over years, is dependent on variables that cannot be impacted by an intensive quick application of PSR, for instance.  People with SPMI get better over time, gradually, when they have consistent therapy, probably from the same person for a long period of time, which is someone they learn to trust, who gently and deliberately challenges them to overcome things like avoiding other people or thinking they cannot work at all or managing anxiety and depression.  Yes, the PSR provides some of the cognitive skills training in an attempt to rehabilitate the person but these are basically chronic illnesses----if a chronic illness can be termed to be something that lasts for a few years +.

Thus, the state is spending an enormous amount of money on these Expanded Services, which are gobbling up the money (the private companies are glad to take it) when the treatment is slower, persistent, deliberate, and consistent.

Basically, the model for 'the cure' vis a vis NC DHHS is all wrong.

And basically, just as with all that money 'lost' under the old Community Support Services, which was an Expanded Service, 'the cure' is a slow, deliberate, planned-out, trust-based, professionally delivered mental health service and not some intense what-to-do-with-the-mentally-ill-person-during-the day.

This matter, of course, is not untethered to the: 1. lack of jobs 2. less and less participation of, say, Vocational Rehabilitation Services which used to do 'job coaching' and obtain jobs for these kinds of people 3. lack of transportation 4. collapse of sheltered workshops where these people can learn some skills although some people call them 'sweatshops.'  And the inability to work and improve oneself is not unrelated to the fact that if someone is receiving disability payments-----and most Medicaid patients receive 'a check' which is usually around $650-850/ month, not including Food Stamps and Section 8 Housing----you cannot work/ gross more than about $750/ month or you begin to lose some of your disability check.

I can't tell you how many disabled clients I have had who have to watch like hawks how much they are getting paid lest they have to pay back some of their disability monies.  This certainly discourages them from working and work is associated with more than just earning money; it is associated with learning social ease around others, having friends, keeping a schedule, etc.

NC DHHS will NEVER fix the outflow of money for these Expanded Services, which is soaking up most of the Medicaid money, along with the LME employees who all earn 50 grand + / year w/ benefits----until they get the model right.  And the correct model associated w/ this population, which is the SPMI, Severe Persistent Mental Illness population, such as people with schizophrenia; schizoaffective disorder; Borderline Personality disorder; severe depression or bipolar disorder; and Dissociative Identity Disorder (which is present in this population more than most people think and it is associated with severe sexual/ emotional/ physical childhood abuse)----is a model associated with the treatment of a chronic illness not rehabilitation and a quick voila fix utilizing very expensive, stacked services which the private companies are only too glad to provide.

Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC

Friday, July 27, 2012

Medicaid Waiver: Emergency Board Meeting for WHN LME re: 3$ Million in Red & Damning Mercer Report

I received an e mail from the CEO's Executive Secretary yesterday indicating there would be an 'emergency meeting' of the WHN LME Board re: the $3 million short-fall.  The agency is only 6 months into its Medicaid Waiver.  There is no more money available; that is part of the Medicaid Waiver. When its gone, its gone, lest the LME turn to the counties.  You think they're going to come up w/ money? I don't think so.

And, I still sit and wait to get my Out of Network (OON) Provider application through.  Since WHN LME will not be satisfied w/ 2 letters or recommendation (from this Medicaid provider who has been in the system for over 10 years) on company letterhead, I have to get my two references to fill in a form.  I dare not have them send the information to WHN LME untethered from my OON application for it will get lost.

And I just went over the 10 page form for my Medicaid client w/ a severe sexual abuse history who dissociates.  Prior to the Medicaid Waiver, I had no paperwork to turn in except for the one page Value Options 'Request for Reauthorization.'

So, now what we have is an LME consuming most of the Medicaid money, going broke, greatly diminished services to Medicaid clients and the specter of a SMC LME take-over. WHN LME is sandwiched in between the two regions of SMC LME. 

With this continuing kind of management, that is undoubtedly what will happen. 

This is not particularly a good thing either.  SMC LME may be better organized (there is a lot to be said for that) but they are requiring webinars re: the clinical and billing issues which is 8 hours of unpaid provider time.  Plus, the person who organizes that at SMC LME failed to put me into last week's classes though she said she would and so now I have to wait until August 8th which means that I have no ability to bill for my Medicaid clients under SMC LME which started its Medicaid waiver on July 1, 2012.

And, to my mind, a sad note: here is a video of SMC LME employees tauting the joys and benefits of the Medicaid Waiver on you-tube.  Maybe some of them are in hoodies because they do not want to be identified:

Oh, gee: 'this video has been removed by the user'

Well, to describe it would be difficult but basically it was the IT/ Utilization Management Departments of SMC LME dancing around, whooping joyously about the benefits of the Medicaid Waiver. 

I guess the CEO nabbed it before it went viral but unfortunately for him, plenty of people saw this silly video which outlined an LME's employees, pulling down 50+ grand/ year w/ benefits, w/ time to make a goofy video about a subject which has done nothing but shortchange providers and citizens of NC who have mental health challenges.
Whoopee! Let's hear it for the Medicaid waiver.

WE NEED A ONE PAYOR SYSTEM not all these bits and pieces scattered everywhere.

Medicaid Waiver: If I Were Working at WHN LME, I'd Not Be Sleeping Well at Night: Damning Mercer July 2012 Report

Remember: the Mercer audits, reportedly an independent audit of an LME's functioning, does not include any information from consumers or providers.  This is, in any case, a very damning report and matches my experience w/ Western Highlands Network (WHN) LME. 

For instance, re: massive disorganization and lack of efficiency in the LME, right now, I cannot get my Out of Network Provider application in because, unlike Smoky Mountain Center (SMC) LME, I must get the 'proper forms' of the Universal Provider Applicationn, filled out by my references, even though I have letters of reference on company letterhead from those references.

I predict that SMC LME will consume WHN LME.  If you look at the map of the LME's, you will see that WHN LME is sandwiched between the two regions of SMC LME.[1].pdf

Here are some salient points from the Mercer Report (this compay has been overviewing the mental health reform process in NC for 5+ years that I know of): These were the areas that were reviewed:

Review Findings and Recommendations .................................................................... 2

• 1. Management Reporting ..................................................................................... 2

• 2. Financial Operations ......................................................................................... 4

• 3. Information Technology and Claims .................................................................. 5

• 4. Clinical Operations ............................................................................................ 7

• 5. Next Steps ......................................................................................................... 9
I am speaking here to "Clinical Operations" only:
And I note only one item which jumps out at me: If, which is true, that claims must be submitted within 90 days of service in order to be paid (NOTE: prior to Medicaid Waiver, providers had up to one year to submit claims) and the information is not reviewed efficiently, how can clients/ consumers continue to receive services?
I note the following tidbit from the Mercer Report:
"......4d. Finding: The process for report development is cumbersome. Quality management

staff meets with clinical managers to develop reports and then the reports are prioritized

by senior management. Historically, clinical management reports are low priority,

resulting from claims management and financial reporting challenges and the need to

focus resources on provider payments. However, this has left clinical management staff

with gaps in information necessary to manage care effectively and efficiently.

RECOMMENDATION: Elevate priority for clinical management reports recommended in this

report for completion within 30 to 60 days and allow senior clinical staff access to database for

data queries as indicated in 1c above. "

Saturday, July 21, 2012

Medicaid Waiver: It Allows the Removal of Medicaid Eligibles from the Medicaid Rosters: the Feds Giveth and the Republican-led States Taketh Away: NYT : Debate in Maine; Wisconsin; AZ

Ah, well, it now becomes so clear: the purpose of the NC Medicaid Waiver is to remove Medicaid recipients from the Medicaid rosters. This takes place as associated with the slip-sliding of eligibility requriements; the lack of health care providers (as is the case regarding Western Highalnds Network LME); and who knows what else they have up their sleeves.

This, at a time when more and more people are going onto Medicaid due to the economy and loss of jobs.
Better come up with a ONE PAYER SYSTEM.
There's a comprehensive article in the NYT this past week which overviews the Medicaid Waiver and its associated with 'Obamacare' or better said, the Affordable Care Act. The more Republican a state is, the more the state is trying to cut the Medicaid rolls.
And there's a WHOLE LOT of comments when you google the title of the article. So, there are lots of entities/ people weighing in, including the Kaiser Foundation, which the health care attorney from Philadelphia advised me last week, was a site to watch re: Medicaid Waiver matters.
Here are some interesting excerpts and here is the URL:
(Governor of Maine declares)...."he is planning to cut thousands of people from Maine’s Medicaid rolls, arguing that the recent Supreme Court ruling on the law gives him license to do so......

Federal officials insist that while the ruling allowed states to opt out of a planned expansion of Medicaid, it left intact all other aspects of the law affecting the program......

Ever since the law was enacted in 2010, governors of both parties have complained about its requirement to maintain Medicaid eligibility levels, saying it has hamstrung their efforts to balance budgets during a period of excruciating economic pressures. But the federal government has generally not relented on the so-called maintenance-of-effort requirement.....
Before last month’s ruling, Mr. LePage had planned to seek a federal waiver to remove more than 20,000 people from MaineCare, the state’s Medicaid program. But he now says that the ruling made a waiver unnecessary.
“Maine believes the Supreme Court decision confirms that states have the flexibility to manage their Medicaid program without risking the loss of federal funds,” Adrienne Bennett, Mr. LePage’s spokeswoman, said in an e-mail.

Dennis G. Smith, secretary of the Wisconsin Department of Health Services, said the requirement for states to maintain Medicaid eligibility standards was “called into question” as a result of the Supreme Court decision......
Arizona was already operating its Medicaid program under a waiver. The Obama administration allowed the state to change its program, freezing enrollment for childless adults, after the waiver expired last September. In April, the administration allowed Wisconsin to start charging monthly premiums to some Medicaid beneficiaries and to deny coverage to others who had access to affordable employer-sponsored health insurance.......
Several law professors said the Obama administration appeared to be on solid ground in refusing to let states tighten eligibility standards.

“I do not think Maine can do what it wants to do,” said Professor Nicole Huberfeld, an expert on health law at the University of Kentucky....."

Wednesday, July 18, 2012

Medicaid Waiver: All the Little Ways that Piedmont Behavioral Health Has Benefited from the Medicaid Waiver

Well, I just finished 2.5 hours of non paid training in order to bill for my Medicaid clients under SMC LME. Prior to this,before the Medicaid Waiver, I simply went to 'webclaims nc medicaid' and it took me 5 minutes / client for multiple outpatient therapy sessions to bill.

Now, I have to fill in boxes of information which is associated with a piece of Software, Alpha CMS, which was created by a 'spin off ' group (I am quoting Robert Webb, the IT guy at SMC LME who led most of this computer webinar training this afternoon) from Piedmont Behavioral Health, the LME who started the Medicaid Waiver in 2005. 

PBH are/ were using, Mr. Webb stated, the 'Cardinal' system and (undoubtedly) the smarter ones or less unethical ones, seeing the opportunity to peddle their software to the LME's, sold it and developed it to SMC LME and other LME's in eastern NC.

Of course, only half of the LME's in NC wanted Alpha CMS which is utilized to do all of the authorizations and billing associated with Medicaid and state funded clients. The other half of the LME's, including WHN LME, use another kind of software.

I'll make a wager: the other half of the smart people who 'spun out' of Piedmont Behavioral Health created the other software that the other LME's are using.

Since the Medicaid Waiver is funded by the feds and state tax dollars, how is it that people who were employed by Piedmont Behavioral Health were able to use what they learned while developing the software for PBH and go out and create a fortune by privatizing their publicly funded knowledge?

My, that's a strategy that Mitt Romney would applaude.

Friday, July 13, 2012

Medicaid Waiver: Prior to Waiver, 1 page of paperwork Obtained Services; Post Waiver, 17+ pages of paperwork Keeps the LME Busy and Eats up the Medicaid Money

This is a tragic miscarriage of public mental health. There are 17 pages to be filled out and mailed to WHN LME in order that my Medicaid (only; no Medicare) client receive services. Said client has a hx of severe sexual abuse and has a diagnosis of Dissociative Identity Disorder. Said client was raped by step-father for 7 years. Said client uses crack when dissociating. Said client has been arrested 3 x over past 10 yrs re: dissociation. Said client attempts to work and is a gentle-natured person w/ a spouse and 2 children living in ann RV park due to lack of funds. There's a part of me that is determined to reveal this scam for what it is.....regardless of the cost to me in terms of paperwork and irritation and frustration. There is no reason why public monies should be employed to create and support this kind of system, these LME's which are consuming most of the Medicaid money pushing all this paper around. GIVE US A ONE PAYER SYSTEM, PLEASE SIR: This is from the WHN LME page which is only part of creating a file for a Medicaid client to be followed by an Out of Network Provider. __________________________________________________________________________ To Activate a Case Managed Sessions, Enhanced Services PRTF (Psychiatric Residential Treatment Facility) TFC (Therapeutic Foster Care) Form 1: ERF - Enrolee Registration Form (4/3/12) ERF Instructions | ERF (English) | ERF (Spanish) If you have a CCIS log-in, fax to 828-225-2797 to complete documents electronically. Form 2: STR - Screening, Triage, and Referral Form if not completed by WHN in the last 60 days Note: DCCI must also be completed with paper submission. Form 3: DCCI - Description of Consumer’s Clinical Issues (updated 4/13/12) Form 4: LCAD - LME Consumer Admission and Discharge Form To Request Services You will need to Activate the Case and submit the following forms: Form 5: TAR (Treatment Plan) - Treatment Authorization Request (TAR)

Medicaid Waiver: North Carolina Medical Journal: WHN LME Predominantly Outlines Services to Citizens 21 yrs old and less: What has happened to the Adults w/ Mental Illnesses for this LME?

I have a subscription to the NC Medical Journal. A couple of months ago, they devoted the issue to mental health reform. Its full of stats and charts and the initial article outlines what is to be discussed but I am afraid I almost always come away from this journal scratching my head, seeing gaps in terms of 'well, what are the conclusions here given the data' that just puzzles the hell out of me. If there are so many adults w/ mental illnesses, why, for one, is WHN LME talking so much about using their resources for children and youths w/ mental health challenges? (see just below). And if there are going to be a massive number of people coming onto Medicaid rosters as of 2014 (that's less than 2 years away) why wouldn't the LME's be doing everything in their power to pull in all available providers when instead what is taking place is a staggeringly inefficient system which has caused Medicaid providers to flee that arena. I'm afraid this journal is kind of like an etch-a-sketch: I see some form of what is important but the outline is so vague and the missing pieces are so lost in the glossy 'ata-boy' take on matters which, incidentally, are life-threatening to quite a few citizens, that I sadly put it down and just blog on, for whatever that is worth. Here is the link to the issue: __________________________________________________________________ "Planned Changes in Child/Family/youth Services at One LME/MCO Don E. Herring, Marsha L. Ring Don E. Herring, MA/Psy, LCSW director of Medicaid operations, Western Highlands Network LME/MCO, Asheville, North Carolina. Marsha L. Ring, MA, LPA, HSP-PA director of clinical operations, Western Highlands Network LME/MCO, Asheville, North Carolina. Western Highlands Network (WHN) is a local management entity/managed care organization (LME/MCO) managing state and federal behavioral healthcare funds in Buncombe, Henderson, Madison, Mitchell, Polk, Rutherford, Transylvania, and Yancey Counties. In January 2012, WHN had a general population of 535,492 and a Medicaid-eligible population of 80,297. During that month, the network provided services and supports to 7,785 active consumers through state, grants, and Medicaid funding. Of these, 3,075 were Medicaid funded and less than 21 years old. Of these, 3,075 were Medicaid funded and less than 21 years old.The children and young adults we serve, ages birth through 20, have historically been high users of long-term residential placements and psychiatric treatment facility services, which are high in cost and often take these young people far from their families or caregivers..... The waiver is structured to “reward” the LME/MCO for being a good manager of services. One goal is movement from expensive, high-end services of short duration to longer-term, in-home (or at least close to home) services;......".... ____________________________________________________________________________ (From other articles in the NC Medical Journal, URL above: ".....The North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services estimates that 393,151 adults living in North Carolina have a serious, disabling mental illness and that 246,230 children and youth have a serious mental, behavioral, or emotional disorder [1]....." "The adoption of the 1915(b)/(c) waiver allows each LME to manage the size and mix of its provider network to help improve cost-effectiveness while ensuring that individuals have a choice of providers for all services available..." "....Coordination of care is critical to support individuals’ recovery of control over their lives and determination of their decisions if they have a behavioral or developmental disability. Specifically, it is important that individuals who experience a crisis receive prompt follow-up care from a community resource. ...." "....In addition to making reforms in the private health insurance market, the ACA also makes important changes to the federal-state Medicaid program. Beginning in 2014,Medicaid eligibility will be expanded to cover all individuals with incomes at or below 133% of the federal poverty level established by the DHHS....."

Medicaid Waiver: I Cannot Find the Out Of Network Provider Form, Which is Required of Out of Network Providers Who Continue to Follow Their medicaid clients anywhere on the WHN LME website

I just want to make evident how difficult it is working with WHN LME re: being a Out Of Network Provider. This is correspondence between myself, and a very helpful woman, who is simply a tool / a cog in the machine, working at WHN LME: ____________________________________________________________________________ On Thu, Jul 12, 2012 at 8:57 AM, Donna Baker Oliver wrote: > ...... > It has been while since I looked at this application...I thought it > might be useful to point out you will also need to complete the > application to be credentialed in case that piece was overlooked. > Essentially, two applications are needed, instructions found on page 2 > of 9 of the client specific agreement with the corresponding link. > Please let me know if you have questions about this piece. > > Thank you, > Donna > > Donna Baker Oliver, LCSW > Western Highlands LME > Outpatient Provider Network Specialist > 1-800-671-6560 (toll free) > 828-225-2785 ext 2977 (Buncombe) > 828-225-2784 (fax) ________________________________________________________________________ Dear Ms. Oliver: I have no idea where to find the Out of Network (OON) forms now. Most of the links on this page no longer work: Enrollment Forms. I have already sent in via US post the 9 page Client specific Agreement Form for a Medicaid client along w/ my initial DMA 'Medicaid Provider approval' form. I don't know if you are requiring more than this as I cannot find the Client Specific Agreement Form at the 'search' box at the WHN LME website, as it only allows this much to be typed in: ' client specific agre' and no useful information comes up. Therefore, I cannot even see what is on Page 2 of the Client Specific Agreement Form which is to be used by OON providers. Please advise. thank you. Marsha V. Hammond, PhD

Thursday, July 12, 2012

Medicaid Waiver: This is the Procedure to Get Paid by WHN LME for Outpatient MH Services for Out-Of-Network (OON) Providers: Prior to the Medicaid Waiver, everything was Seamless

Can we please have our old system know....the efficient one that allowed Medicare and Medicaid to automatically wrap around to each other? This is bullocks. This is correspondence between myself and Ms Donna Baker Oliver, working in Provider Relations at WHN LME in Asheville, NC. She's a nice lady. But I have a lot of questions. Here is Ms. Oliver's response to earlier general questions I had re: the OON Provider payment and authorization system: ____________________________________________________________________________ On Thu, Jul 12, 2012 at 9:13 AM, Donna Baker Oliver wrote: > I was forwarded this question from our enrollement phone line. Here is > my understanding: > > 1. A separate client specific application needs to be submitted for > each of the three enrollees referenced in the July 4 letter from Melissa > Faulkner. > 2. Even if one of the enrolless has Mcare/Mcaid, in order to receive > reimbursment for the secondary Mcaid you would need to submit that > client specific application for that enrollee. > > 3. You only though need to submit one credentialing application (not > 3). > > I don't know if this helps, when we use the word managed that often > refers to are correct in that Mcare/Mcaid enrollees > services do not need to be authorized. > > Thank you, > Donna > > Donna Baker Oliver, LCSW > Western Highlands LME > Outpatient Provider Network Specialist > 1-800-671-6560 (toll free) > 828-225-2785 ext 2977 (Buncombe) > 828-225-2784 (fax) ______________________________________________________________________________ Thanks for your reply, Ms. Oliver. This is being posted on my blog so that other providers can organize themselves, if they even choose to, re: this OON (Out of Network) Provider status. I have some subsequent questions as I want to be very very clear what you are requiring here re: this OON (Out of Network) Provider information that you need on a client by client basis, something that has taken place automatically for over 10 years but whic his now supplanted by this Medicaid Waiver which has created all this work: 1. am I going to have to recreate a separate 9 page specific application each time I ask for a group of authorizations . If the answer is yes, I will simply copy each one and change the date and signature page. 2. how many authorizations are commonly given and is there any basis on the past rate at which I have been seeing the client that has any relationship to the number of authorizations that are permitted? In other words, does WHN LME have the capability to SEE the medicaid utilization from the past years? 3. Is there any other paperwork that has to be processed in order for me to be paid to continue to see the clients I have been seeing? I note that the WHN LME paperwork indicates that the matter will be processed "within 10 days." Will I receive notice via e mail or how that this has taken place? 4. Who do I speak to when the 10 business days is up and it has not been processed? 5. If I see the client WITHIN THE MONTH e.g., July, that the paperwork was received by WHN LME, am I going to be able to be paid, for example, for July visits or do I have to wait until everything has been processed to bepaid as an OON? 6. OK, you seem to be saying that the dually eligible clients do not have to be MANAGED OR AUTHORIZED but you do need the 9 page form in order that I BE PAID. Am I correct about this? And the tiresome procedure as associated with that, versus the seamless wrap around that was in place re: Medicare automatically wrapping around to Medicaid, is no longer, and I will have to take the Medicare payment information, send it to you, and then wait for what...a check? an automatic deposit into my bank account----which was the way it was done before? 7. What is the additional paperwork for the non dually eligible client-----one with Medicaid only? Is this going to include a Person Centered Plan? If so, he'll need to find another therapist. I just want to know how extensive the paperwork is for the Medicaid only client so I can choose whether to refer him out or not. He is calling me and asking for appointments. 8. When you say that I only need to do only 1 credentialing application not 3, you are referring, I assume, to the : a. tax return of mine you received b. attestation re: emergency contact procedures 3. certification of my expertise (which doesn't seem to matter) 4. W-9. Correct?

Medicaid Waiver: Obamacare or Affordable Care Act: Medicaid Spends Less/ Person than Private Insurance but Waivers Must Be 'Budget Neutral'

">Medicaid is sometimes described as a complex program that is difficult for potentially eligible people, health care providers, as well as policymakers, to understand.  Waivers could be used to make the program less complicated and easier to enroll in and administer, but a number of recent have made the program more complex...... Medicaid played an important role during the most recent economic downturn by offsetting much of the decline in employer-basedcoverage and keeping millions of people (mostly children) from becoming uninsured.......experience with recent waivers shows that increased programmatic flexibility may not be thesolution for addressing state fiscal problems while maintaining access to needed care." NOTE: There is no information in the above Kaiser publication re: any Medicaid Waiver activity as associated with NC.It was published in 2005.

It would take a policy wonk to understand all of this but here goes. This Medicaid Waiver matter is ALL related to the expansion of Obamacare in 2014. As more and more people go onto Medicaid rosters, Medicaid Waivers become more and more likely.

Key words include 'neutrality' (it does not cost the Fed government more to implement the waiver than it would to not implement it). Or as more clearly stated in the below, " It limits a state’s 
access to open-ended federal financing, putting the state at risk for costs that exceed the cap
and creating the potential for the state to experience additional fiscal stress over time.  ..."

From the Kaiser Foundation, as recommended by the Philly attny familiar w/ Medicaid Waivers, mentioned in a previous Defarge post:

Here is a excellent overview of Medicaid Waivers:


Medicaid finances health coverage for low-income families and elderly and disabled people.
Often poorer and sicker than the privately insured, Medicaid enrollees rely on the program for
preventive, medical, and long-term care services.  The federal government and the states jointly
fund Medicaid, with the federal government paying 50% to 77% of the costs, depending on the
state.  States administer the program guided by a combination of federal standards and state
options that qualify them to receive federal matching funds.

Section 1115 waivers give states federal approval to alter the way they provide coverage and/or
deliver services to the low-income population outside of the federal standards and options and
still receive federal matching funds.  That is, they allow states to use federal Medicaid funds in
ways not otherwise allowed under federal law.  States have used waivers to test and try a variety
of changes affecting program coverage and costs throughout the 40-year history of the Medicaid
program.  For example, in the mid-1990’s a number of states relied on waivers to require
beneficiaries to enroll in managed care, a service delivery option that later became available to
states without a waiver.  Tennessee, Oregon, New York and others used waivers to significantly
expand coverage to new groups, using managed care savings or redirected Disproportionate
Share Hospital (DSH) funds to meet budget neutrality requirements of the federal government.

Waivers have been used in good and bad economic times both to try new ways to provide
coverage for the low-income population as well as to try alternative approaches to contain costs.
Over the past few years, as states have faced significant budget shortfalls and increasingly
difficult fiscal situations, new federal waiver guidelines offered states increased programmatic
flexibility through waivers and new financing mechanisms to meet budget neutrality
requirements.  This combination of severe fiscal pressure on states and increased flexibility has
led to a new round of waiver activity.  Recent waiver activity has focused on reducing coverage
to relieve state fiscal pressures....."


How are states currently using Section 1115 Medicaid demonstration waivers?
 States have used waivers for many purposes, including to expand coverage, change delivery
systems, alter benefits and cost-sharing, modify provider payments, and quickly extend coverage
during an emergency.
 Currently, 30 states and the District of Columbia operate one or more comprehensive Section 1115
Medicaid waivers that involved an estimated $54.6 billion in federal outlays in 2011. These waivers
generally fall into several categories, including waivers to implement managed care, to expand
coverage with limited benefits, to restructure federal financing, and to expand coverage to lowincome adults in preparation for the Medicaid expansion in 2014.

How does the Affordable Care Act (ACA) impact Section 1115 waivers?
 The ACA does not change the key provisions of Section 1115, but IT DOES REQUIRE NEW REGULATIONS TO INCREASE THE TRANSPARENCY (caprs are mine)of the approval process and creates new waiver authorities.  Since the passage of the ACA, several states have obtained Section 1115 waivers to expand coverage to low-income adults in preparation for the coverage expansions under reform. Other states haveexpressed interest in pursuing waivers focused on reducing costs to address budget shortfalls.

Medicaid Waiver: I talked to the Health Care Attorney: Medicaid Waivers Aggressively Moving Across the US

Well, I talked on the phone to the attorney in Philly who represents clients who have complaints about Medicaid waivers.  He basically said that it is a ploy to un-do Obamacare---an attempt to cut costs as Medicaid rosters increase as the middle class goes increasingly belly-up (the last bit is my take on the matter).  It will continue and accelerate, he stated.

He suggested I research the matter from the perspective of 'medicaid waiver' and 'GAO' and 'Kaiser Foundation.'

And there's not a damn thing to be done about it.

Pennsylvania, in particular, he cited, as having a behavioral health care Medicaid Waiver. So, there is no presumption that this is a discriminatory practice e.g., putting a Medicaid Waiver onto behavioral health care while not doing so re: physical health care.

Amazing, isn't it?

As the moniker for this blog states: "The more things are different, the more they are the same" (translated from the French).

Or to paraphrase the matter, the closer we get to universal/ one-payer health care, the greater will be the push to increase the barriers to such.

Turning NC Medicaid into an HMO is one such strategy.  And they have succeeded.

Wednesday, July 11, 2012

Medicaid Waiver: Health Lawyers Speak Up RE: Medicaid Waivers across the US

From: Marsha V. Hammond, PhD  Clinical / Health Psychology  NC Licensed Psychologist
cell: 828 772 1127 e mail: 
TO: Mark H. Gallant  []  Cozen O'Connor  1900 Market Street  Philadelphia, PA 19103  (215) 665-4136

RE: Medicaid Waiver 1915bc in NC Which Only Attends to Mental Health Management

Date: July 11, 2012

Dear Mr. Gallant:

Thank you for the information included here: MEDICAID MANAGED CARE:

I looked over the lawsuits which are briefly outlined at the end of your pdf. Here is my question: How is it that a state, the state being NC, can utilize a Medicaid Waiver, for Mental Health ONLY? There is no Medicaid Waiver associated with Medicaid, in general-----only as associated with mental health authorities or LME's/ MCO's, as they are termed in NC.

It seems to me blatant discrimination as associated with that population, specifically, the MH/ SA/ DD population which is commonly associated with disabled people.
I would appreciate speaking to you about this matter at your earliest convenience. I called your office and left a message.
Thank you.

Marsha V. Hammond, PhD, Licensed Psychologist, NC

Medicaid Waiver: NC Medicaid is now an HMO and Original Tenet of Mental Health Reform, CHOICE, Has Been Undone

Well, that's about the sum of it.  NC Medicaid re mental health is now an HMO.  Take it a step further: mental health services for Medicaid clients is now regulated as associated with NC having been granted, by the Feds, apparently, this Waiver .

So, we have Medicaid that has nothing to do w/ behavioral health services that has NO Waiver restrictions; and then we have the discrimination of this 1915bc Waiver as pertaining to mental health services. 

That doesn't seem quite right and it seems to me that is not in keeping with the NC law that was passed a few years ago disallowing such discrimination.  But I'll have to review that.

The excuse that WHN LME is using in order to bar me from being an In-Network provider is that I turned in my application two weeks late.  However, what can also take place for any Medicaid provider over the first year as being a provider In-Network to any of the LME's, is that they can discard you.  Its like being on probation for a year.  And I would not be surprised if they can continue to do that, thus completely silencing all the providers from saying anything negative about the LME's AT ALL.

Here is the letter I received from Bill Bullington at NC DHHS; he is the liason w/ the LME's:


"Dr. Hammond, you are incorrect that Medicaid requires the network to be open for one year. Rather, there was a meeting between DMH and DMA in which it was considered appropriate, that for the first year, an enrolled provider could only be terminated from the LME/MCO network "for cause" (based on performance, fraud/abuse, monitoring results, etc). This consideration only applied to those enrolled in the network prior to the LME/MCO go live date.

My understanding is you did not comply with the open enrollment process offered by Western Highlands and therefore were not an enrolled provider in their network as of Jan. 3, 2012. Western Highlands provided an open enrollment period allowing more than sufficient time for eligible providers to complete, submit and become enrolled as a network provider prior to Jan 3, 2012. Applications received after that date had no guarantee of being reviewed or processed.

After Jan 3, 2012 Western Highland began operating as an LME/MCO which includes the ability to close or open their network based on service need and the ability to terminate a provider from their network based on the consideration stated above.

I hope this provides you with sufficient clarification regarding your issues and the roles and responsibilities of providers and LME's in meeting established deadlines necessary to successfully complete and participate in the 1915 (b) (c) Wavier process.

Here is the link to the waiver which certainly deserved investigating:

Tuesday, July 10, 2012

Medicaid Waiver: Medicaid Requires LME Networks to Remain Open to Medicaid Providers 'for at least one year'

This is a series of correspondences, via e mail, between myself, WHN LME, and DMA, indicating that the LME's, as they re-credential Medicaid providers, must leave the network open to Medicaid providers 'for at least one year.'

Thank you for your note, Ms. Faulkner. I cc Mr. Reuss here also as you indicate he is the head of Provider Relations at WHN LME.

I turned in my original filing to be an In Network Provider to WHN LME 1.23.2012. Yes, your deadline was 1.3.2012 but Medicaid requires the network to be open for one year.

It is therefore not acceptable that I am not able to work as an In-Network provider, given that I have been one for Medicaid in NC for over 12 years. I have special expertise working w/ DID clients and have a doctoral psychology degree and am better trained than most of the mental health providers in NC, frankly. I have no sanctions or violations re: Medicaid or my license.

IMHO, you are simply barring me because I have had such a lot to say about the inefficiency of the WHN LME re-credentialing process. I am being processed at SMC LME and so what's the problem w/ WHN LME?

Here is what DMA has to say about the deadline matter: (see also below the complete e mail from Bert Bennett, PhD): "Medicaid requires that the LME under the labor open its doors for all existing Medicaid providers for a minimum of one year."

I therefore cc this to Mr. Bullington who is querying WHN LME about the difficulties I have experienced being allowed to be an In Network Provider at WHN LME.

Marsha V. Hammond, PhD
cc: Ureh Lekwauwa, MD, Clinical Director, DMA NC

Bill Bullington, LME liason, DMA NC


Bennett, Bert

Feb 27

to Katherine, me

Dr. Hammond:

Thank you for your questions. As for the name and contact and permission for Secretary Cansler's replacement, that would be Al Delia as Acting Secretary of the N.C. Department of Health and Human Services. His telephone number is: 919-855-4800 and his e-mail address is:

The next question about Western Highlands and their ability to close the network, Medicaid requires that the LME under the labor open its doors for all existing Medicaid providers for a minimum of one year. During that year, the LME/MCO has the ability to evaluate the capacity of their network and, after a year, they do have the ability to choose which providers will be in their network.

Thank you for sharing some of the specifics of the difficulties and "barriers" that you have dealt with. I will pass this information on to the individual responsible for managing the contracts with Western Highlands. I am sorry that you had such difficulty transitioning to the MCO.


Bert Bennett

Bert Bennett, Ph.D.

Division of Medical Assistance

Clinical Policy, Behavioral Health Section

2501 Mail Service Center

Raleigh, NC 27699-2501

336-724-4539 - Voice

336-722-2899 - Fax

On Tue, Jul 10, 2012 at 8:43 AM, Melissa Faulkner wrote:

Ms. Hammond,

WHN conducted an open enrollment process from April – December 2011. WHN did not receive an enrollment application from you during that time. As of January 3, 2012 WHN began operating as a closed provider network.

WHN does recognize that there are currently three enrollees receiving services from you. The client specific applications were offered to prevent a disruption in their care.

Lastly, one minor correction, I am not the Director of Provider Relations at WHN. Donald Reuss is the Director of Provider Network Operations. I hold the position of Network Operations Manager.
Melissa Faulkner

Provider Network Operations

Western Highlands Network

356 Biltmore Avenue

Asheville, NC 28801

Phone: (828) 225-2785 or (800) 671-6560 Ext. 2922

Fax: (828) 225-2796

Saturday, July 07, 2012

Medicaid Waiver: If Providers are Denied In-Network Status, There is no Ability to Appeal: Republican Driven NC State Legislature Has Allowed "Fewer Restrictions" = No Accountability to NC Citizens

The NC State Legislature, in passing a bill this past week, has allowed the below to happen.  There is now next to no accountability to citizens, including providers, as as result of Representative Dollar's bill.  Here is an excerpt from Richard Craver's article about the matter which can be found at:

"....The waiver program is intended to combine the management of Medicaid and state funds at the community level to reduce costs and add more accountability. MCOs would operate with fewer restrictions on how they manage the mental-health, developmental-disability and substance-abuse providers and services they oversee.

State Rep. Nelson Dollar, R-Wake, a co-sponsor of the bill, said, "The concept of BHA will likely be looked at in the future, but I think the primary focus over the next year or two will be the successful conversion of the LMEs to LME/MCOs fully functioning in the waiver environment."

Perhaps the most controversial portion of the bill is allowing MCOs to keep as confidential "competitive health care information." Advocates have protested the confidentiality inclusion, saying an MCO should not be allowed to designate information or products as proprietary — then license them as a revenue stream — if they were developed through taxpayer money....."
My e mail regarding being denied In-Network provider status at Western Highlands Network LME was sent to Mark Grimaldi, NC DHHS as advised by attorney Amanda Reeder, at NC DHHS.

He sent my concerns to Bill Bullingto, as per the e mail below.
"Grimaldi, Mark

4:37 PM (20 hours ago)

Hi Marsha,

Thank you for sending us your concerns. I am forwarding this email chain to Bill Bullington at as he is the LME liaison and can speak with them regarding your concerns."

Marsha V. Hammond, PhD, Licensed Psychologist, NC
cell: 828 772 5197
e mail:

July 7, 2012

RE: denial of veteran Medicaid provider to In-Network status at WHN LME

Dear Mr. Bill Bullington:

I have 40 years of health care experience.  I have been licensed as a psychologist for 17 years.  I have no sanctions or violations associated with my practice.  I have special expertise in working w/ people needing outpatient therapy who have Dissociative Identity Disorder (DID) which is associated with a history of severe sexual, physical, and emotional abuse.  Why am I being denied access to WHN LME In-network status? There are very few well trained practitioners who work w/ this population. 

We no longer have Medicaid if you think of Medicaid as being a health insurance provider that allows access to any willing provider.  Western Highlands Network LME has refused to allow me to become an In-Network provider even though I have been a NC Medicaid provider----with no violations or sanctions whatsoever----for over 10 years.

NC Medicaid is now an HMO.  That means that the LME's can decide, without appeal, whether providers are to be accepted in to the network or not.  Amanda Reeder, an attorney in the NC DHHS, advised me yesterday that there is no ability to appeal as associated with the 1915bc waiver.  The LME's are allowed to determine 'capacity'----whatever that means.

This means, of course, that any provider who has any complaints about an LME should keep their mouth zipped lest they not be allowed to be an In-Network provider. 

It has become nigh impossible to work w/ WHN LME.  I have complained a great deal about the inefficiency of this LME in terms of their re-credentialing of Medicaid providers who have been utilizing Medicaid.  This has not made me popular.  No other providers will speak out and you can ask journalists Richard Craver, mental health writer, Winston Salem Journal 'Now', or journalist Casey Blake at the Asheville Citizen-Times.

I appreciate you looking into this matter, Mr. Bullington. Please, please: let's not have a long conga line of 'pass the buck' which appears to already be happening re: my concern going from Amanda Reeder, then Mark Grimaldi, then you, with frequent cc's to the Chief of Clinical Policy, Ureh Lekwauwa, MD.

My understanding, from a psychologist working at DMA was that 'the network' was to remain open 'for at least a year' but this very obviously is not what is taking place. 

Does NC DHHS want this Medicaid waiver to succeed----or not? You already have many mental health providers who have opted out of working any longer w/ Medicaid.


Marsha V. Hammond, PhD

Medicaid Waiver Under WHN LME: without In Network approval, paperwork must be filled out one 9 page submission at a time

This is great. For each of my Medicaid clients, I have to fill in 9 pages of paperwork, include a W-9, face page of my malpractice policy, and try to get answers to questions like this, on page 8:

On page 8 of the Client specific Agreement application there is a

check box entitled: " direct enrollment w/ DMA for each service


What does this mean?? Does it mean that as I am a licensed

psychologist that I can provide outpatient mentalhealth services?

I just don't get what it is asking for. please advise ."

Then I have to print off the 9 pages, sign it with an original signature, send it via US mail to WHN LME, and then wait to hear from them. 

This is nothing but a ploy to use up all the Medicaid money doing paperwork rather than direct patient contact.  This is nothing more than a sleight of hand such that the LME's use most of the Medicaid money in administering this ridiculous amount of paperwork. 

Makes them look like they are doing something when in fact, they are simply devouring the Medicaid $$, leaving little for the care of Medicaid patients

Things were MUCH BETTER and efficient when it was centralized and Value Options was receiving the authorization requests and webclaims was being used for billing.

These 9 pages of paperwork has to be done patient by patient.  How did it USED to be? As a Medicaid Provider, I sent in a one page authorization request after the 8 unmanaged sessions were used, and Value Options sent me back verification of what I had requested.  Then I billed for those sessions, on line, quickly, as part of webclaims for NC DHHS------and not as associated with going thru some convoluted training process individuated LME-by-LME. 

HOW, I ask you, is this going save money? Or is the agenda to drive as many providers out of the Medicaid network as possible and have the LME's use the lion's share of the money?

This is just plain TRAGIC.

Friday, July 06, 2012

When LME's Deny In-Network Status to Medicaid Providers under Medicaid Waiver, There is No Appeals Process

From: Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist
cell: 828 772 1127
e mail:

TO: Mark Grimaldi, LME Systems Performance Team, 919 715 1294, NC DHHS,

RE: Denial of In-Network for long-term Medicaid Provider

July 6, 2012

Dear Mr. Mark Grimaldi, of NC DMA, LME Systems PerformanceTeam:

I was directed to call you by Amanda Reeder, attorney working in the Department of Mental Health.  She advised me that when an LME denies In-Network capabilities to a Medicaid provider, such as myself, a Licensed Psychologist, there is no appeals process.  Why is that? Medicaid is not an HMO.  But it appears to be functioning as a HMO related to the 1915bc Waiver.

Here is the reply I received from Melissa Faulkner, Director of Provider Relations at WHN LME.  Noteably, I am not getting the same problems w/ being an InNetwork Provider from SMC LME.  Instead of 'katie bar the door', I am recently receiving helpful information back from SMC LME.

I am including what I put on my blog re: the matter. I think you might speculate that because of my documentation of all the problems at WHN LME regarding my re-credentialing, they would rather limit me to my current Medicaid patients.

I find this curious when so many Medicaid providers out this way have simply thrown in the towel.

Thank you for your response to me, in advance.

Marsha V. Hammond, PhD

Medicaid Waiver: Vastly Different Strategies Between WHN LME and SMC LME: One Blocks Providers While the Other Invites Them In

Here is the letter I just received from the WHN LME Provider Relations Director, Melissa Faulkner, restricting me to seeing the Medicaid consumers that I currently have and no others:

"July 4, 2012

Marsha V. Hammond, PhD

Dear Status Provider Enrollment Application Request:

We would like to thank you for your interest in enrolling with Western Highlands Network (WHN). Your request has been approved for Client Specific Applications. The enclosed application allows you to request client specific agreements to serve WHN enrollees.  The award of a client specific contract does not permit you to serve any additional enrollees of the WHN Network.  At present, WHN is aware of the following enrollees in your care:------------Please do not admit any new WHN enrollees without prior approval from WHN....."

Contrarily, SMC LME seems to be moving, even though chaotically, towards enrollment of all legitimate providers (best I can tell) and as per my phone conversations with Patty Wilson, Senior Provider Relations Manager.

Why is this? If I were paranoid I might think they were trying to shut me up.

So, here is my letter back to Melissa Faulkner:


Dear Ms. Faulkner, Director of Provider Relations WHN LME:
Thank you for your reply. 
May I inquire as to your rationale regarding your non-desire to allow me to be an In-Network Medicaid Provider when I have 40 years of working in health care settings, w/ over 15 of them as a doctoral level psychologist? 
I have no ethical violations, no violations of any kind and am better trained than most of the mental health providers in the area. 
Moreover, because of my advanced training, I have expertise in working w/ people w/ severe persistent mental health issues and as you know, the ACT teams provide no therapy for these seriously mentally ill people-----the ACT teams being a source of referrals for me as those people become more stabilized such that they can benefit from therapy. 
Thank you in advance for your reply. 
Marsha V. Hammond, PhD, Licensed Psychologist, NC
cc: Ryan Whitson, Board SMC LME; Arthur Carder CEO;
Ureh, Lekwauwa, MD, NC DHHS; Sally Cameron, Executive Director NC Psychological Association

Monday, July 02, 2012

Medicaid Waiver: Smoky Mountain Center LME Cannot Efficiently Process my Request for Re-certification as a Medicaid Provider Because They Have no Ability to Ascertain if I Have Been Paid for Seeing Medicaid Patients Under Their Catchment Area, Even Given my Medicaid Provider # and Even Though They Administer Medicaid

I have noted the HIPAA tag at the end of Ms. Barlow's e mail which states:


"Pursuant to NC G.S. 132-1, any email sent to and from this email account may be subject to the NC Public Records Law and may be disclosed to third parties.
Pursuant to HIPAA Regulation 160-160.514, this email message is intended only for the use of the named addressee and may contain information that is confidential or privileged. If you are not the intended recipient, or you are not the employee responsible for delivering the email message for the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this email message is strictly prohibited. If you have received this email message in error, please notify the sender immediately"
There is no confidential patient information as associated with her e mail; therefore I am posting this in order that other providers, news media sources, and concerned citizens regard the difficulties of working w/ NC Medicaid, specifically as associated with mental health, under this Medicaid Waiver which has required that the LME's e.g., Smoky Mountain Center LME, Western Highlands Network LME, re-certify already certified Medicaid Providers.

.Here is my conversation with the recipient of my 40 pages of Provider Recertification information which came to her office today.  Apparently, SMC LME, though they are the administrators of Medicaid, has no ability to tell if Medicaid has paid me for services rendered over the past 6 months as associated with the SMC LME catchment area.  I find that amazing.
Here is my e mail to Ms. Barlow, processing the re-credentialing papers for already in place Medicaid providers:

Thank you, Ms. Barlow, processor of Provider Credentialing paperwork, as per Smoky Mountain Center LME, for your e mail.

I do not seek to be a contrarian; rather, I want to work smoothly with organizations who can organize themselves efficiently.

The item that you are asking about, specifically "SMC does not show (that you have) billed Medicaid on any SMC consumers within the last 6 months"----- is not on the checklist provided by SMC LME as being associated with what you demanded re: re-certification of Medicaid providers. I do recall reading something about that somewhere in the SMC LME provider re-certification information but no, it was not on your checklist as associated with items that MUST be submitted.

I would like to know why SMC LME cannot obtain from NC Medicaid, information about me, a Licensed Psychologist, with a Medicaid number, as having seen and been paid by Medicaid? Are you not privy to any of that Medicaid information given that you are administering Medicaid information? I gave you my Medicaid number on the application materials

Sending you Medicaid information on clients is not as easy as it was, as I assume you know. NC Medicaid stopped sending out any paper information over a year ago. Thus, I will have to go online, pull up the information, print out the information, and fax you the information.

I will send you the requested Medicaid client info.

I find it difficult to believe that you cannot turn up that NC Medicaid has paid me in the past 6 months, frankly.  You have all the information in front of you, including my Medicaid provider number.  You should be able to pull up hundreds of mental health outpatient therapy sessions' coding and payment processes.

Marsha V. Hammond, PhD

Here is Ms. Barlows e mail message to me regarding that she see that I have been billing Medicaid

On Mon, Jul 2, 2012 at 11:49 AM, Karen Barlow wrote:
> Dear Provider:>

Smoky Mountain Center (SMC) received your Provider Enrollment application on
 July 2, 2012, as postmarked June 29th. SMC does not show that your
 organization has a contract with us or has billed Medicaid on any SMC
 consumers within the last 6 months; therefore we will be glad to accept your
 application but it will not be processed until after July 1 and at that time
 SMC will make a determination of acceptance within our network based on
 capacity and need.>

You may provide evidence of eligibility to SMC by sending a copy of a
 Remittance Advice (RA) for dates between 01/01/12 and 06/30/12 that contains
 behavioral health billing codes linked to Medicaid numbers originating from
 one of the SMC 15 counties. The enrollee’s county must be in the SMC 15
 county catchment area, which include the following: Alexander, Allegheny,
 Avery, Ashe, Caldwell, Cherokee, Clay, Graham, Haywood, Jackson, Macon,
 McDowell, Swain, Watauga, and Wilkes. Please redact any other identifying
 information before sending. Be certain that you identify the Medicaid
 number, the county of origin and highlight the corresponding Medicaid number
 on the RA.>

 You may submit evidence via scan email to or fax it to my attention at

 If you have any further questions or concerns, please submit via email at

Thank you for your interest in Smoky Mountain Center.
 Karen D. Barlow
 Credentialing Specialist/Support
 Smoky Mountain Center/Central Region
 825 Wilkesboro Blvd, NE
 Lenoir, NC 28645
 828-759-2160 x 3330

Sunday, July 01, 2012

United Health Care Dual Complete HMO SNP: Medicare Advantage Plan Disguising Itself as Medicare

So, I'm looking at the letter from United HealthCare to a client of mine (providers get a different set of explanations, ya know).  This is a long term client of mine who switched from standard Medicare to United HealthCare, a reportedly 'Medicare Advantage Plan' (they have an administration rate of 15% + while regular standard Medicare has an administration rate of 5%: go figure) about six months ago and I sent a complaint to the NC Insurance Commissioner re: the sleight of hand associated with they not paying me as I was 'out of network.' 

She has since switched back to standard Medicare . And so when I sent the complaint re: non-paid charges to the NC Insurance Comissioner, they called me, indicated it was 'being investigated by Medicare' and assumeably I am to be paid.

I've been a Medicare provider for over 10 years.   These plans are 'supposed' to simulate Medicare. 

But they obviously do not.

So, I researched her plan, which is described in her letter from United Health Care as the following plan:

"......This is a Medicare Advantage plan for people on Medicaid who also qualify for Medicare – commonly known as "dual eligible." It's intended for people who live in a community setting, receive financial help (such as SSI) from their State Medicaid program and have Medicare. This plan includes all Medicare Part A (Hospital) & B (Doctor) benefits and Part D prescription drug coverage. It also provides benefits not offered by Original Medicare.
This plan is available in the following counties: Alamance, Buncombe, Caswell, Catawba, Chatham, Cumberland, Davidson, Davie, Durham, Forsyth, Guilford, Haywood, Henderson, Mecklenburg, Orange, Person, Randolph, Rockingham, Rowan, Stokes, Surry, Wake, Wilkes and Yadkin.
Call Us at 1-800-905-8671 or let us call you (TTY# 711 for hearing impaired) 7 days a week from 8:00 a.m. to 8:00 p.m. local time...."

In looking at her letter which is associated with paying me my Medicare Provider fee, it states the following interesting information:

1. "Plans are insured or covered by an AFFILIATE of UnitedHealthcare Insurance Company, a Medicare Advantage Organization with a Medicare contract and a Medicare-approved Part D sponsor."

OH, so we're at the level of 'an affiliate.'  This basically means, re: this sleight of hand, that the 'affiliate' can act as an HMO which indicated to me in errors codes as my biller attempted to recoup my charges, that I was 'out of network', which, of course, is an HMO ploy.

My client indicated that she had wanted nothing to do w/ HMO's/ PPO's re: all our collective information associated with the debacles of in/ out network brouhahas.

My, what a tangled web we weave.

Why Did WHN LME Hand Out Paperwork at the June 22, 2012 Board Meeting Indicating that the NC Council of Community Programs Which Oversees the LME's Has Created a 'Central Repository' for Provider Re-Credentialing When It Does Not Exist?

FROM: Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC e mail: cell: 828 772 5197

TO: The Two Board Officers for the NC Council of Community Programs, overseeing the LME’s in NC:

1. Betty Taylor, Area Director President CenterPoint Human Services 4045 University Parkway Winston-Salem, NC 27106 (336)714-9118

2. Ken Jones, Past President , Area Director Eastpointe 100 South James Street Goldsboro, NC 27530(919)731-1133

AND, Regional Representative for the Western part of NC:

3. Ed Tarleton Area Board Member Smoky Mountain Center PO Box 183 Glendale Springs, NC 28629 (336) 973-8618;

4. Arthur Carder Area Director Area Director Pathways Western Highlands Network 356 Biltmore Ave Asheville NC 28801;

5. Rhett Melton Gastonia, NC 28054 Asheville, NC 28801 (704) 884-2501 (828) 225-2785

DATE: June 28, 2012

RE: NC Council of Community Programs Handout at the June 22, 2012 WHN LME Board Meeting indicating there to be a ‘Statewide Issues Resolution’ re: Provider Credentialing

Dear Ms. Taylor, Mr. Jones, Mr. Tarleton, Mr. Carder, and Mr. Melton:

I am writing to inquire about the matter associated with a hand-out at the June 22, 2012 WHN LME Board meeting. It is on the NC Council of Community Programs letterhead. On page 2, it indicates that there has taken place a “Statewide Issues Resolution” as associated with the very pressing issue of “Need standardized application process for providers across all LME-MCO’s. ” Moreover, on page 2, in the same box, the memo states that there has been the creation of a “Central repository established for provider application.”

I am currently engaged in provider credentialing for SMC LME and WHN LME . The applications are completely different. Therefore, there is obviously no ‘Central Repository’ or even a similar application process.

For WHN LME, the provider re-credentialing takes place in poorly planned stages with the first stage being the submission of one’s tax return; statement of what will occur if there is a patient emergency; a declaration of what kind of expertise/ patients one has been seeing. Then one waits for months to hear an answer. I have been trying to be re-credentialed by WHN LME for over 6 months.

For SMC LME, there is one stage of re-credentialing which includes the following: 20 page form associated with items which one has already outlined in the demanded CV; copy of my psychologist license; copy of any other states’ psychologist license; my doctoral university transcript; CV; 2 letters of recommendation from ‘similar’ practitioners’; 2 page checklist which must be filled out; W-9 IRS form; face page of malpractice insurance.

Do you see any similarities between those two re-credentialing processes?

This is a massive hardship for providers. It is therefore an injustice as per NC citizens. If you need details on that, please see my blog which has been documenting this:

So, why does your paperwork indicate that this ‘Central Respository’ has been created----- when it has not? And moreover, why didn’t your organization consider the difficulties that providers would experience as associated with the a la carte method which has been utilized by the various LME’s in order to re-credential already Medicaid credentialed providers?

It appears that your organization is simply a lobbying mechanism (you state you have 2 lobbyists: for the LME’s. And, the LME’s appear to have massively failed regarding their No 1 mission which is to smoothly transition this Medicaid Waiver. Since 2002 the LME’s have simply been managing state-funded clients (those who cannot qualify for Medicaid and have no other health insurance). That is ALL the LME’s have been doing, to the tune of millions and millions of $$.

There is no standardization for the re-credentialing of providers and by your non-fulfillment of what you state you have done e.g., “creation of Central Repository”, your continued existence appears to be simply a mechanism to create work for the LME’s who continue to absorb most of the Medicaid money rather than it being employed for the treatment of NC citizens.

I am thanking you in advance for your response. I want to know why your letterheaded statement indicates that there is a ‘Central Repository’ when obviously there is not one. If there is a ‘Central Repository’ for re-credentialing, a matter which was suggested by NC DHHS as regarding the use of the CAQH credentialing process----which providers have been using for years----then someone needs to inform SMC LME and WHN LME that it’s there.


Marsha V. Hammond, PhD, Licensed Psychologist, NC