Medicaid Waiver: Western Highlands Network Inability to Respond to Emergent Situation re: My Medicaid Client

From Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist
cell: 828 772 5197
e mail: chomskysright@gmail.com

TO: Bill Bullington, Liason for Western Highlands Network, NC DHHS  e mail: bill.bullington@dhhs.nc.gov
telephone number for mental health at NC DHHS 919 733 7011 (ask for 'LME team' and Bullington is liason for WHN LME)

Date: October, 22, 2012

RE: inability of WHN LME to work w/ Out of Network providers seeing Medicaid clients

Dear. Mr. Bullington:

Thank you for your assistance.  I will outline the issue and then tell you who I have contacted.

Most of my Medicaid clients, fortunately, are under SMC LME, which functions quite well.  However, I have one client, of which I have spoken many times to WHN LME specifically, beginning in February, 2012. The client is asking for an emergency meeting (I have continued to see him intermittently this past year though he needs regular mental health due to his severe mental health diagnosis) TODAY.  I will see him.

In order to continue to work w/ my Medicaid patients, and as associated with wanting to utilize my training as a doctoral level clinical psychologist, I attempted to be an In Network Provider w/ WHN LME beginning w/ my application January 25, 2012.  The deadline for that as per WHN was 1.3.2012.  Then I attempted to become an Out of Network Provider.  They reviewed, reportedly, my application for this OON on September 20, 20112.

I expected a letter. When I did not receive one, I called.  I then sent a certified return letter to the interim CEO, Mr. Schoenfeilt over a week ago.  I have received no call and not even the certified letter return has come back to me.  I then contacted the head of Provider Relations by phone call, once today, and once yesterday, Donna Baker Oliver re: this matter of the OON and more pressingly the matter of seeing my client.  I also, today, called the CEO's office and left a message.  As of now, I have heard nothing from either one.

Can you please cut through the red tape so that I can be authorized (paid) as I have for years, as associated w/ rendering my doctoral level psychologist services to my clients under WHN LME? Can you please discover what papers/ materials they may be missing re: my OON application?  I have spent 10x as much effort to simply drive through this OON provider recredentialing w/ WHN LME as I have w/ the SMC LME as pertaining to this very unhelpful Medicaid Waiver.

SMC LME has none of these issues.  I get people on the phone; I get return calls; I get people telling me that I am authorized to see clients.

thank you for your help.

Marsha V. Hammond, PhD, Licensed Psychologist, NPI 1194700591; Medicaid Provider: 6000320; Medicare: 249 2758

cc: Brian Ingram, CEO SMC LME

No Response from Western Highlands Network LME CEO re: my Out of Network Medicaid Application: the Perils of the Medicaid Waiver

From: Marsha V. Hammond, PhD
Clinical / Health Psychology
NC Licensed Psychologist
cell: 828 772 5197

To: Donna Baker Oliver, Provider Relations,working w/ solo practitioners at Western Highlands Network LME-MCO   e mail: donnaba@westernhighlands.org

RE: Out of Network re-credentialing application for long-time Medicaid provider

Date: October 22, 2012

Dear Ms. Oliver:

Today, Kelly, in Provider Relations, advised me that you are the contact person for the re-credentialing process for Medicaid providers as associated w/ solo practitioners .

I was advised that on Sept 20, 2012, my Out of Network (OON) application would be reviewed. I first submitted an application to WHN LME on Jan 25, 2012.

 I heard nothing after the September 20, 2012 meeting and so 10 days ago called WHN and asked what is going on.  That person advised me to 'call back' if I did not have a letter.  I do not have a letter from WHN LME.

I then sent a certified return letter to the CEO of WHN LME advising him that I had attempted to become an In Network provider, was refused for no reason other than my application was received after the January 3, 2012 deadline (January 25, 2012, to be specific).  I also outlined my continued attempts to be an OON Provider.  I have heard nothing from him.

What other materials do you need from me in order to establish myself as an Out of Network provider? I have Medicaid clients in your catchment area that I have continued to see even though I am not being paid to see them.

Prior to the Medicaid Waiver, Medicaid in NC worked very efficiently.  Authorizations were submitted to Value Options and my billing was done, by myself, very quickly and dependably, online at an HP interface.

After the Medicaid Waiver, I was required to sit through 8 hours of non-paid training at Smoky Mountain Center LME in order to utilize their alpha computer software, which is not up to speed, and therefore I had to submit my authorizations to continue to see my Medicaid clients by fax/ paper.  Fortunately, they were OK w/ this.

I now have to pay double for my biller to do my Medicare/ Medicaid billing (many clients are 'dually eligible' and  have both Medicare and Medicaid).  Prior to the Medicaid Waiver, Medicare automatically wrapped around to Medicaid.  Now I pay my biller twice as much for the same billing.  .

Contrary to Western Highlands Network, Smoky Mountain Center LME very efficiently moved through my In Network Provider application.  It has been very easy to work with them.  It has been extremely difficult and time consuming trying to work w/ WHN LME.

This is not helpful to Medicaid consumers nor to Medicaid providers.

Pass this information to anyone you like.

Sincerely,

Marsha V. Hammond, PhD, Licensed Psychologist

cc: co-chairs of Joint Legislative Oversight Committee for Mental Health/ DD/ SA: Louis.Pate@ncleg.net, "Rep. Justin P. Burr" , Nelson.Dollar@ncleg.net

I'm Praying that Smoky Mountain Center LME Takes Over Western Highlands Network LME-MCO

Western Highlands Network LME-MCO, is sandwiched in & between the north and south of Smoky Mountain Center LME.  SMC LME is, I believe, the largest LME in NC.  I'm impressed by the helpful attention that the personnel at SMC render to me, just a solo provider, in terms of authorizations and explanations re: their mostly non-functional alpha computer system (so far; they seem motivated; maybe they will fix it so I can put my authorizations into their alpha system rather than submitting them by fax like I used to for Value Options).   Today, for instance, a person in the authorization part of SMC called me to let me know that I did not need to render a 'Service Order' as associated with my authorizations for I am a licensed psychologist.  That was very helpful. 

This is tax payers money.  This is how they should be working w/ providers.  We are the people who provide the services that they are administering.

Contrarily, WHN LME-MCO, appears to be completely unhelpful at every level. 

I sent a certified return letter to the CEO (interim CEO subsequent to Arthur Carder being fired a couple of months ago due to the LME needing to ask for an infusion of $3 million) from the state). 

Here is that letter.  When I get to the point that I am ready to press a 'restraint of trade' suit, well, the fact that this was certified return, may come in handy.  I hope it doesn't come to that.  I simply do not know how to get WHN LME moving.  I have Medicaid clients under their jurisdiction----one who is in prison right now-----but I cannot get even an Out of Network agreement with them established.  They're asking for yet more paperwork, apparently, but I have no letter and no information about that.  I called them last week and that's what they told me.  They need yet more paperwork from this licensed psychologist who has provided Medicaid recipients with services for over 10 years .

PLEASE: SMC LME: make a sustained effort to take-over WHN LME.  I am advised by people at Copestone Partial Hospitalization---people who work there----that they have also 'heard bad things about Western Highlands.' 

"Dear WHN CEO, Charles Schoenheit:

I applied to be an In network Provider on 1.25.2012.  I was denied.  No clear reason was given other than I had not met the deadline. I attempted to again in March/ april, 2012. I was denied.  I applied as an Out of Network Provider in August, 2012.  I was denied, with the explanation being that yet more paperwork was required. I called Donald Reuss (heads up Provider Relations) onn Wednesday, 10.17.2012, idicating I had not received any paperwork re: "more paperwork required."  I have not heard from him, as I requestsed.  Please forward to me any requested further paperwork.  There are NO judgements/ issues re: my psychologist license.

Sincerely, Marsha V. Hammond, PhD"

Medicaid Waiver: How to Get Your Authorization Requests thru to Smoky Mountain Center Without Committing Suicide After Trying to Use Their Alpha Software Created by Folks Who Spun out of Piedmont Behavioral Health

Well, so I spent an hour on Saturday afternoon---unpaid work----to try and work w/ the Alpha system that SMC LME-MCO bought from computer IT people who used to work for Piedmont Behavioral Health who started all this Medicaid Waiver business.  They spun out of there and reportedly created this Alpha software for SMC LME-MCO and many other LME's in NC.

I can't make the Authorization (SAR: Service Authorization Request) part of it work.  I can't get the thing to save information.  I tried it on my home computer; then I thought, well maybe my Charter connection (fastest in the US! dontchaknow, according to TV commercials) isn't so fast here at home, so I went over to Kinko's----unpaid work----spent $20 to try and make it work there.  Still wouldn't work.

So, I went to the SMC web site and pulled down a two page SAR and printed it out. 

There was no information about which fax number to send it to, so I sent it to the main/ central office and that's not the right place.  So, I just called up the 586 5501 and asked to speak to the 'Authorization' people and thankfully ended up w/ Fannie who was very helpful. 

She advised me that the correct fax number is: 452 3473 and to address it to Deana Owens.  I will be sending deana.owens@smokymountaincenter.com an e mail later today or tomorrow to see if she received the SAR requests, 3 of which are expedited. 

Do NO send the 2 page SAR paper request to the central office.  Fannie could not find out where the expedited authorization request disappeared to that I sent Saturday night.

Do you think that SMC LME-MCO might have put this information where providers could find it? Naw.

They spent all that money on a piece of computer software for which I had 8 hours of unpaid training to try and manipulate---and I can't make it work.  I'm not a nerd but gee whiz, I've done online university teaching and managed a blog and my e mail so give me a break: your software sux, SMC.  Better get a refund from PBH.

Oh, I forgot: those employees worked for PBH, then took their hard-won knowledge and created a private enterprise from their government-based jobs----just like Lanier Cansler, head of NC DHHS until a few months ago, has done twice now. 

Nice work, if you can get it.  Question is: would a morally upright person want to take to the cleaners the tax payers who paid for your job so that you could go out and create private enterprise. 

This sounds suspiciously like a  Bain Capital maneuver.

My Submission to 'Ask a Question' to the Smoky Mountain Center website re: Non-Honoring of Value Options Authorizations

The 'excuse' that SMC LME came up with, as it started its Medicaid waiver in the middle of the year e.g., July 1, 2012, was that 'we realize that some providers don't have in place their authorizations and so we are extending 8 (adult) sessions for outpatient therapy and 16 (age less than 21) sessions for outpatient therapy."

UH: We had already put into place the authorizations in accord with what we did EVERY year prior to the Medicaid waiver in order to seamlessly see out clients and be paid.

Not only did your point person at SMC LME assure me that 'surely the LME will honor the VO authorizations' and not only did the head  honcho at NC DHHS Raleigh tell me that the LME would honor the VO authorizations, but there is not even any information that I can find (sorry: I am not going to spend hours digging thru the massive SMC LME web page) CLEARLY INDICATING THAT THE VALUE OPTIONS AUTHORIZATIONS WOULD NOT BE HONORED AND YOU HAD TO START FROM 'GO.'

So, here is my question to whoever is behind the Wizard of Oz screen at SMC LME:

But FIRST a gleaming list of why its so great to have this Medicaid Waiver from the SMC LME website:

"Advantages to a Publically Managed Waiver for Providers…
 More predictability in their business relationship with the LME.
 The ability to negotiate reimbursement rates in relationship to service needs and clinical
priorities.
 Strong, existing relationships between LME and providers in meeting consumer service
needs.
 Shared stewardship, rewards, and satisfaction in meeting outcomes are primary motivators –
instead of big impersonal corporate profit-taking.
 Keeping funding and control for home and community-based services where it works best:
the home and community we share together.
 Greater ability to help consumers access services and supports to compliment their services,
because they are part of an organized system of care, regardless of payer.
 Direct access to decision-makers – at LME, community Board of Directors, county
government.
 The opportunity to participate in planning for service expansions.
 LME’s are able to create incentives to assist providers in developing, maintaining or
expanding needed services.
 The Opportunity to grow your business as new consumers are able to access services
through planned expansions, and subsequent greater market share.
 Regular sources of pre-authorized referrals and local Utilization Management
responsiveness are inherent in the model.
 Recognition and marketing presence afforded to LME network presence.
 Valued voice in monitoring and improving LME operations with regular avenues for
feedback.
 Consistent source, timeliness, and manner of payment and documentation, with local staff
available to support providers.
 The advantages of economic stimulation for the local economy by keeping funds in your
communities, instead of out-of state co...

blah blah blah....." See it here: http://www.smokymountaincenter.com/documents/medwaiv/PublicManagmentofMedicaidWaiver_and_AdvantagestoProviders.pdf

First of all, I had a completely dependable relationship between authorizations at Value Options and providing outpatient therapy to my Medicaid clients.  The ONLY reason for the Medicaid waiver is to save money, so let's not beat around the bush and try to paint it as having some other rationale.

And, moreover, it saves money off the backs of the providers.  When providers have to engage in a process which pays them nothing and takes hours of additional work in order to be paid for their work, that means that money is saved due to having screwed the providers.  Point blank.

It does not create more seamless mental health care delivery.  It is not helpful to the clients when the providers cannot work with them because the authorizations are so difficult to come by.

I spoke to the authorization head at SMC a couple of days ago and she stated that for 'Expedited' authorizations, there would have to be 'medical necessity' and a long list of explanations.  The turn-around time is 3 days, if that is even granted (I am betting it is not).

Otherwise, there is a 14 day turn-around.

When Value Options was managing Medicaid, there was a special fax number for 'Expedited' authorizations which were immediately forthcoming.

Now I wait; my clients call me or just get sicker; and we all wait around for SMC and WHN (gave up on them) to get it together----all the while they talk about what a swell thing this Medicaid waiver is.

                                                     BULLSHIT.

Here is my question (it will never get answered, you betcha) to SMC LME:

"Why is there not a clear statement---easy to find---right out in front---re: the LME NOT using the already in place Value Options authorizations?

Why did your point person advise me that SMC LME would 'surely' honor the VO authorizations?  Why did one of the head honchos at NC DHHS in Raleigh indicate to me that the VO authorizations would be 'good', only to find that she had not read the April Medicaid bulletin which indicated what her own agency had decided to do which was to allow the LME to 'start from GO' re: the authorizations e.g, July 1, 2012, as re: SMC LME?

Thank you and now I head over to the Alpha system to recreate all the authorizations that I created back in March, 2012, so I can be paid to do my work.

Contrarily, you are being paid to answer this e mail. I am paid nothing to ask you this question; I am being paid nothing to spend my Saturday afternoon doing authorizations which were already in place back in March, 2012.

Respectfully, Marsha Hammond, PhD"