Saturday, October 06, 2012

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
 Strong, existing relationships between LME and providers in meeting consumer service
 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
 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
 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:

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.


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"


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