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


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