Saturday, September 29, 2012

Heads of NC DHHS Medicaid Don't Even Know About Authorization Issues: Don't Bother Asking Them

I expected SMC LME to honor the Value Options authorizations that had been put into place the beginning of the year.  Sorry, but I don't have time to read every single Medicaid bulletin.  This message is from a key person at NC DHHS/ Medicaid:

Nichols, Katherine A
Sep 27 (2 days ago)
to meStephentoni.shelow
Dr. Hammond,

After doing some research in the old special bulletins, I found in the April 2012 bulletin the following excerpt:

Outpatient Behavioral Health Services in LME-MCO Areas
The unmanaged outpatient visits for adults and children will start over for each LME-MCO. In
the current Medicaid State Plan, adults may have eight (8) unmanaged outpatient visits and
children may have sixteen (16) unmanaged outpatient visits each calendar year. LME-MCOs
can increase the number of unmanaged visits per calendar year before prior authorization is
required, but may not decrease the number of unmanaged visits. LME-MCOs are required to
publish their Medicaid benefit packages on their websites.

Therefore, SMC was correct in starting their unmanged visits back over beginning July 1, 2012.  I believe they also communicated this on their website and in provider meetings.  I apologize for my error, but please note the correct information above.

Please don't hesitate to contact me should you have any further questions.



Wednesday, September 26, 2012

My Letter to Joint Co-Chairs for Committee on MH/ DD/ SA

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

TO: Senator Louis Pate – Co-Chair
406 Legislative Office Building
Raleigh, NC  27603
O: 733-5601

Representative Justin Burr – Co-Chair
538 Legislative Office Building
Raleigh, NC 27603
O: 733-5908  Email:


Date: 9.26.2012

Dear Mr. Justin Burr and Louis Pate,co-chairs for Oversight Committee for Mental Health, Developmental disabilities, and Substance Abuse:

You are the co-chairs for the Joint legislative Oversight Committee associated with mental health.

What has your committee determined to be the process for the continuation of mental health care as associated with the Medicaid Waiver which has been in effect for SMC LME since July 1, 2012? Is the LME-MCO supposed to carry forward the authorizations which providers put into place, as they were required to create at the beginning of the year, authorizations which were managed by Value Options (managed by them for years prior to this medicaid waiver).

SMC LME apparently is allowing 'some'------whatever authorizations were passed to them by VO-----of these authorizations to be utilized and on the other hand, what 'we didn't get', has been simply ignored.

I look forward to speaking w/ you this afternoon about this important matter which is effecting mental health in NC.

If I cannot be paid for my work, then I cannot do my work.


Marsha V. Hammond, PhD

Smoky Mountain Center Refuses to Make Good on the Value Options Out-Patient MH Authorizations Put into Place Earlier this year.

This is great.  Now I have to do all my authorizations again....hours and hours of unpaid work.  Why, you ask.  Because, apparently, SMC LME-MCO, who started their Medicaid waiver July 1, 2012, has refused to to utilize Value Option's (the company who has been doing Medicaid waivers for years) authorizations.  They will use SOME OF THEM----the ones that got pulled over apparently----but not all of them.

This leaves me losing HUNDREDS OF $$.

Time for a call to the NC State Legislature Joint Legislative Oversight Committee for Mental Health.

Here is my correspondence between Toni Shelow, Care Management Director), at SMC LME-MCO:

From: Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist
cell: 828 772 1127
Medicaid Provider Number: 6000320
NPI: 1194700591
e mail:

TO: Toni Shelow, x 1223, Care management director, SMC LME

RE: you don't seem to have the authorizations for my clients from VO

Hi Ms. Shelow:

I left you a message; Ms. Gossman a message; Mr. Ingram a message; Ms.
Stiles I talked to x2.

You do not seem to have been able to gather up the authorizations I
put into place in February, 2012, from VO, though they indicate per
telephone call today, that you should have that info.  What I very
much do not want to do is to go thru each dually eligible or medicaid
only client and obtain the authorization number and parlay that to you
so that I can be paid for what I was authorized for months ago.
Moreover, I have no idea where to put the authorization number as per
the CMS 1500 form.

Specific to my phone call today, I am asking about simply one client
(there are many others; let's start here):

initials: --------------------------------------------------- VO
today, on the phone, authorization beginning 3.16.2012 thru
12.31.2012---- for 43 sessions is: 01-031612-51-37.

Can you obtain that info so that I can bill?  Where do I put that on
the CMS 1500 form?

 Or do I need to give you the authorization numbers from VO----which
they indicate has been passed to you?  As you know, I must bill within
3 months of rendering services and that would be the end of September.

Please advise.

Thank you.

Marsha V. Hammond, PhD

(There is no confidential information in that e mail and so I am posting it)
Toni Shelow
8:51 AM (2 hours ago)
to Stephenmefanny.gossmanBrianSharon
Ms. Hammond,

I received your voice message and I apologize for any difficulties you are encountering. For your clients who are receiving basic benefit services, those restarted on July 1, giving you 8 unmanaged sessions for adults and 16 for children.  While VO had authorizations that went through the end of the year, as an MCO we did not transition basic benefits to the end of VO's authorization.  In order to bill for your clients past the basic benefit number of sessions you would need to submit a Service Authorization Request (SAR) for the sessions that you deem medically necessary for each client.  Keep in mind also that in January, the basic benefits will be re-set again and you will be able to have 8 and 16 unmanaged sessions again prior to requiring authorization.  If you have any addition questions or need further assistance please let me know.

Toni Shelow, Psy.D.
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.
Marsha Hammond,PhD
11:32 AM (3 minutes ago)
to toni.shelowbriansharon.stiles
You are kidding me.

You're saying that you will not make good on the VO authorizations.

I was told by Sharon Stiles (I think: I may be wrong here and I am not
trying to blame her) that if I could pull forward indication that
there were additional authorizations originally created by VO, that
they would 'surely' be good.

Is this written in your rules and regs or do you just determine that
this is the way it will be?

Are there not any other providers to have something to say about this,
the fact that you have completely dismissed the authorizations that
were put into place by VO?

I will call Mr. Ingram in a bit and cc him now.  And then I think I
will call the co-chairs of the Joint Legislative Oversight Committee
for mental health.  They need to know that this is taking place and
further wrecking public mental health in NC....if they even care.

this is really too much.  We do all this work re: authorizations, do
what we are supposed to do, and then you pull the rug out from under
us in the middle of the year.

Thanks.  I await your further information.

Marsha V. Hammond, PhD

Sunday, September 09, 2012

The Bunkum on Buncombe County in the NC Medical Journal re: Medicaid Recipient Usage and Its Comparison to the Non-Insured and Costs if They were Added to the Medicaid Rosters

Hello Penn State:  what do you know about Buncombe County, NC?  And why would the editors of the NC Medical Journal allow researchers who do not understand the lay of the land to publish an 'Original Article'?

My comments, sent to the editors:

From: Marsha V. Hammond, PhD

Clinical / Health Psychology

NC Licensed Psychologist

cell: 828 772 5197

To: North Carolina Medical Journal editors

Re: July/ August 2012 article: "The Cost of Medicaid Coverage for the Uninsured: Evidence From Buncombe County, North Carolina" ; authors: Hwang, W, Griffin, K, Liao,K, , Hall, M.
I would like to submit this as a "Correspondence" comment which I see you feature in the journal which I have been taking for several years. Thank you for considering this submission. I did have a 'commentary' submitted in the past, about a year and a half ago, which was published.


Disabled vs Non-Disabled Buncombe County Residents Would Have Provided a Clearer View of Possible and Future Medicaid Usage in Buncombe County, NC

In the July/ August NCMJ, Hwang, W., Griffin, L, Liao, K, and Hall, M, located at Penn State University, which is decidedly not in NC, provided information concluding that "...uninsured adults would have incurred costs 13% greater than those of the actual non-disabled adult Medicaid population." It would have been useful if the authors had defined, "disabled" and "non-disabled" or if the editors of the journal had required them to define this.

As a resident and mental health provider who lives in Buncombe County and who has at least taken a look at the Project Access (volunteer providers) participation which these authors outline to be a cornerstone of their data gathering----and which they conclude in their Limitations as problematic in that, "some volunteer physicians provided no treatment information, and those that did provide such information had less incentive to report all possible diagnoses", I have to conclude that the basis for their conclusions is erroneous re: the 13% greater costs if the uninsured in Buncombe County were to be enrolled in Medicaid.

What is the basis for the authors' conclusion that these two populations are comparable?

As a clinical psychologist, I know very few adult clients who are Medicaid recipients and not disabled. Indeed, Western Highlands Network (WHN) LME, the mental health administrative entity, located in Buncombe County, published in January, 2012, that there are approximately 80,000 Medicaid eligible citizens in Buncombe County. Given that the authors stated that "Non-Disabled Medicaid Enrollees" total about 22,000, this means that the bulk of the Medicaid recipients in Buncombe County are Disabled. To paint a picture of the uninsured who are serviced by the very difficult to work with Project Access (I have spoken with them in the past) as representative of Buncombe County's Medicaid recipient is disingenuous. Did the Penn State authors understand how underutilized the Project Access is? Did they understand that mental health providers do not work at all, best I understand it, with Project Access? What, indeed, is the usage rate of mental health services for the approximately 80,000 Buncombe County Medicaid Enrollees?

Moreover, is a "Non-Disabled" adult someone who receives Medicaid but no Social Security Benefits? This would outline someone who has not been able, or is not inclined, to move through the rigorous Social Security Disability procedure, a matter which commonly requires the assistance of an attorney. The basis for the authors' conclusion is associated with the comparison of 'non-disabled' Medicaid Enrollees and uninsured patients who have approached and been serviced by Project Access (though how complete the record gathering was for these patients who were given free treatment is very questionable).

The population that the authors seek to compare to the non-disabled Medicaid Enrollees, in the parlance of NC mental health care, would be 'State Funded Clients': non-insured/ non Medicaid clients living at or below the Federal Poverty Level. And until the Medicaid Waiver program was put into place as of January 3, 2012, by Western Highlands Network (WHN) LME-MCO, the administrative arm of NC DHHS as regards Medicaid mental health clients, very few providers would work with these 'State Funded Clients' as associated with the onerous paperwork required to be filed w/ WHN LME.

Now, however, as associated with the Medicaid Waiver, which was hoisted onto the backs of providers across NC, providers who continue to see their disabled and non-disabled Medicaid recipients must have filled out 45 pages of re-credentialing paperwork in order to continue to be paid by Medicaid---if they were allowed to remain "In Network", and the procedure for being paid to see Medicaid clients has become as difficult and time consuming as was previously true of working with the State Funded Clients.

Thus, a more timely article, from authors who understand what is taking place regarding the fairly disastrous NC Mental Health Reform, which started in 2000, would have reviewed these overlapping issues: 1. what is a non-disabled Medicaid patient; 2. why choose non-disabled Medicaid recipients as a population useful for comparison with the Project Access non-insured when approximately 75% of Medicaid recipients are disabled in Buncombe county if one takes the authors' adult non-disdabled Medicaid Enrollees as accurate information.

There are many more salient questions that could be researched by those who have some understanding of just where we have been and where we are regarding NC mental health reform----if you consider mental health care to be part of health care, that is. Project Access may not have much to do with mental health care, but to paint a picture of 20% of Medicaid recipients as comparable to non-disabled non-insured Project Access patients has muddied our understanding of who out there needs Medicaid and what this might cost. We need clarity, not research that does not relate to what has mostly taken place in Buncombe County and NC, in general.