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.

http://projects.newsobserver.com/sites/projects.newsobserver.com/files/WHN_Final_Report[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. "