(About to Be) Largest LME in NC unable to manage fine points of Medicaid re: payment to providers
This is a long series of e mail exchanges between myself and the head of Claims at Smoky Mountain Center LME which, as a reminder, will be taking over Western Highlands Network LME 10.1.2013. It will be---by far---the largest LME in the state. There is nothing confidential in these e mails and so I am publishing them on my blog so that other providers can see that the LME's continue to not be able to 'manage' Medicaid. It is not acceptable.
Sorry to continue to be the pain in the arse to these LME's but someone should do it.
Start at the end and you will see just what a mess NC Tracks is. NC Tracks is some weird thing that took over Value Options and HP Enterprises who were doing just fine until the LME's took over 'managing' Medicaid. Do I smell consulting by former Secretary of DHHS, Lanier Cansler, "Mr Revolving Door", in and out of government/ in and out of consultation... here? I wonder if Lanier Cansler has anything to do with these entities that took over, specifically "CSC is Computer Sciences Corporation, the entity that NC DMA contracts with to deliver and administer the NC Tracks MMIS Claims Processing system."
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Dear Mr. Tax: thanks again for your suggestions. As re: professional organizations, I have joined----and unjoined---- the NC Psychological Association x2 over the past 13 years and will not join again because they give not a fig about public mental health. I will be contacting Tony Puente PhD over in Wilmington and his colleagues who interface w/ CMS and American Psychological Association. "Forty day roll-out" means very little to me re: NC Tracks. I am losing money every minute re: the non-continuation of a link between Medicare and Medicaid as associated w/ SMC 'managing' Medicaid. And as I explained, NC Medicaid did not have this problem re: no ability to 'pass' if you will, the 96152 Medicare code over into Medicaid prior to the LME's 'managing' Medicaid. I will call Vicki at NC Disability Rights. And maybe you know a good attorney? There is a Medicaid appeals attorney over in Charlotte who was doing a lot of work re: appeals as associated with public legal defense system. Its not OK that SMC LME is not finding an answer to my very legitimate question. If you have some more ideas, then let me know. Have a good day. Sincerely, Marsha V. Hammond, PhD
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My final suggestions:
Ø You’ll find ample references to CSC and the NC Tracks system in the NC Medicaid Bulletins (monthly) and any posted Communications Bulletins. See: http://www.ncdhhs.gov/dma/bulletin/index.htm
Ø Use the published Customer Services contacts for phone, email, etc. that are provided for CSC, NC Tracks, and NC DMA. Know that the lines/ queues may be long as we are not yet at the 40-day mark for the new system roll-out.
Ø Confer with any Provider Groups, Licensing Boards or advocacy group to which you may belong. They are often tracking issues for their memberships…
Best wishes. Thank you again for your consideration.
Paul
Paul Tax, Claims Director
Smoky Mountain Center
paul.tax@smokymountaincenter.com
828.586.5501 x. 1170
From: chomskysright@gmail.com [mailto:chomskysright@gmail.com]
Sent: Thursday, August 08, 2013 12:37 PM
To: Brian Ingraham; Sonia Eldridge; Paul Tax
Cc: Julia Sinclair; Patty Wilson; Donald Reuss; bert.bennett@dhhs.nc.gov; Lisa Slusher
Subject: RE: (cont'd) re: 96152 coding wrap-around
Sent: Thursday, August 08, 2013 12:37 PM
To: Brian Ingraham; Sonia Eldridge; Paul Tax
Cc: Julia Sinclair; Patty Wilson; Donald Reuss; bert.bennett@dhhs.nc.gov; Lisa Slusher
Subject: RE: (cont'd) re: 96152 coding wrap-around
Mr. Tax: Thanks for the information. Here is the webpage for CSC: http://www.csc.com/. It appears to be a gigantic corporation and there is absolutely no information re: anything associated w/ NC Medicaid evident there. Moreover, in maintaining my role as chief complainer as associated with both WHN LME and SMC LME (although SMC has improved greatly over the years) the NC Tracks is a barrier also. Just who do I call in NC Tracks? Oh for the days of HP and VO. I find it very vexing that I have to spend so much time putting back into place a system which worked well prior to the LME's taking over Medicaid. I have now telephoned Dr. Bennett, a psychologist within Behavioral Health at DMA, x2, leaving very specific messages; I have seldom caught him at his desk. I have sent him all the information you have sent to me in two e mails today. If you have any other suggestions, please do pass them on to me. Thank you. Again, 96152 is the most correct code for me to use given what I am doing which is pertaining to integrating health care between myself and the medical providers of my clients. Moreover, it pays me at the medical rate, specifically, 80%, rather than the mental health pay of 50%. I think you can understand why I am being so persistent here, particularly in light of having successfully used this code FOR YEARS as associated my dually eligible Medicare/ Medicaid clients. Sincerely, Marsha V. Hammond, PhD
CSC is Computer Sciences Corporation, the entity that NC DMA contracts with to deliver and administer the NC Tracks MMIS Claims Processing system. In an earlier period, I would have referenced HP.
See: www.nctracks.nc.gov
Hope that clarifies.
Thank you
Paul
Paul Tax, Claims Director
Smoky Mountain Center
828.586.5501 x. 1170
From: chomskysright@gmail.com [mailto:chomskysright@gmail.com]
Sent: Thursday, August 08, 2013 12:09 PM
To: Brian Ingraham; Sonia Eldridge; Paul Tax
Cc: bert.bennett@dhhs.nc.gov; Lisa Slusher; Patty Wilson; Julia Sinclair; Donald Reuss
Subject: RE: (cont'd) re: 96152 coding wrap-around
Sent: Thursday, August 08, 2013 12:09 PM
To: Brian Ingraham; Sonia Eldridge; Paul Tax
Cc: bert.bennett@dhhs.nc.gov; Lisa Slusher; Patty Wilson; Julia Sinclair; Donald Reuss
Subject: RE: (cont'd) re: 96152 coding wrap-around
Mr. Tax:
Thank you for your reply. What is CSC that you refer to accordingly: "I would advise you to confer with Dr. Bennett or others to determine if there is an option for you to bill secondary claims to NC DMA via CSC for the dual eligible consumers that you referenced, as this is a non-covered service with SMC. "?
I note your NC DMA doc below. It does not pertain to me. As a Medicare enrolled psychologist, for the past 8 years, I have reliably used 96152 for MEDICARE ONLY .
96152, was never and undoubtedly never will be a Medicaid code for use by psychologists. It is a MEDICARE CODE as per psychologists. That is not the issue here.
For dually eligible clients ONLY e.g., those w/ Medicare as primary and Medicaid as secondary----until 1.1.2013----when SMC took over Medicaid for its catchment area----I reliably submitted and was paid, via my biller, Compuclaims Plus, 96152 for Medicare FIRST----as it is primary----and then NC Medicaid, via Value Options. NC Medicaid, via Value Options, upon Medicare payment, would then wrap around WITH A DIFFERENT CODE that was a psychotherapy code. It was an automatic wrap-around. I submitted nothing. I only had to submit to NC Webclaims for Medicaid ONLY clients.
And as I stated before, since there is no more NC Webclaims and no more Value Options paying me, I cannot get access to any Remittance Advice statements to reveal that NC Medicaid automatically wrapped around once Medicare was 'engaged', so to speak, for these dually eligible clients .
I will call Dr. Bennett in the Behavioral Health Section of NC DMA again now. I left him a message earlier. I have consulted w/ him intermittently over the years re: vexsome issues.
Dr. Hammond:
I am providing you with couple pieces of information that are the basis for our decision as an MCO to not recognize the 96152 code. Attached is an excerpt from the Behavioral Health Databook that governs our covered services, as established by NC DMA. The 96152 code is not included in that table.
The second reference is a recapitulation of the June 2010 Medicaid Bulletin which references the services that fall under the original waiver pilot (Cardinal Innovation, f.k.a. Piedmont Cardinal, PBH).
Note that while 96152 is referenced, it is only included when provided by a Psychiatrist. As a Licensed Psychologist, you would not be considered an eligible provider of this service to the MCO(s).
I would advise you to confer with Dr. Bennett or others to determine if there is an option for you to bill secondary claims to NC DMA via CSC for the dual eligible consumers that you referenced, as this is a non-covered service with SMC.
Thank you for your consideration.
Paul
FYI
From June 2010 Medicaid Bulletin
Attention: All Providers
N.C. Mental Health, Developmental Disabilities, and Substance Abuse
Services Health Plan Waiver (Formerly, Piedmont Cardinal Health Plan)
Effective July 1, 2010, additional services will be added to the N.C. Mental Health, Developmental Disabilities
and Substance Abuse Services (MH/DD/SAS) Health Plan Waiver. The MH/DD/SAS Health Plan currently
operates in Cabarrus, Davidson, Rowan, Stanly, and Union counties and is administered by the area Local
Management Entity, Piedmont Behavioral Healthcare (PBH). Except for emergency services, all MH/DD/SAS
providers must obtain prior authorization from PBH to qualify for reimbursement of services provided to
Medicaid recipients who, for Medicaid purposes, are residents of the PBH five-county catchment area.
The services listed in the table below will be included in the MH/DD/SAS Health Plan beginning with dates of
service July 1, 2010, when
· the service is provided by a psychiatrist;
· the Medicaid recipient is a resident, for Medicaid purposes, of the PBH catchment area; and
· the Medicaid recipient’s primary diagnosis is in the 290 through 319 range.
If the conditions listed above are met, psychiatrists must obtain prior authorization from PBH to qualify for
reimbursement for these services.
Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes
90865
Evaluation of Implanted Neurostimulator
95970 95971 95972 95973
95974 95975 95978 95979
Standardized Cognitive Performance Testing
96125
Biopsychosocial Assessment/Intervention
96150 96151 96152
Outpatient and Other Visits
99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
Facility Observation Visits: Initial and Discharge
99217 99218 99219 99220
Inpatient Hospital Visits: Initial and Subsequent
99223 99231 99232 99233
Observation/Inpatient Visits: Admitted/Discharged
99234 99235 99236
Inpatient Hospital Discharge Services
99238 99239
Consultations
99241 99242 99243 99244 99245
99251 99252 99253 99254 99255
Emergency Department Visits
99281 99282 99283 99284 99285
Nursing Facility Visits
99304 99305 99306 99307 99308
99309 99310 99315 99316 99318
Domiciliary Care, Rest Home, Assisted Living Visits
99321 99325 99326 99327 99328
99334 99335 99336 99337
Care Plan Oversight: Domiciliary Care, Rest Home, Assisted Living and Home
99339 99340
Home Visits
99341 99342 99343 99344 99345
99347 99348 99349 99350
Prolonged Services Outside Customary Services
99354 99355 99356 99357 99358 99359
Alcohol and/or Substance Abuse Structured Screening
99408
Injections: Diagnostic/Preventive/Therapeutic
96372 96373 96374 96375 96379
Telehealth Originating Site Facility Fee
Q3014
All services provided in emergency rooms to Medicaid recipients residing in the PBH catchment area with a
primary diagnosis in the 290 through 319 range will be included in the MH/DD/SAS Health Plan beginning with
dates of service July 1, 2010. Providers of emergency room services must contact PBH for reimbursement.
These services are currently billed under the following revenue codes:
Emergency Room
RC450 RC451 RC452 RC456 RC459
Behavioral Health and Waiver
Paul Tax, Claims Director
Smoky Mountain Center
828.586.5501 x. 1170
From: Marsha Hammond,PhD [mailto:chomskysright@gmail.com]
Sent: Thursday, August 08, 2013 10:16 AM
To: Paul Tax; Sonia Eldridge; Brian Ingraham
Cc: Bert Bennett
Subject: (cont'd) re: 96152 coding wrap-around
Sent: Thursday, August 08, 2013 10:16 AM
To: Paul Tax; Sonia Eldridge; Brian Ingraham
Cc: Bert Bennett
Subject: (cont'd) re: 96152 coding wrap-around
I am sorry, Mr. Tax. The e mail that you just received fired off before I could finish it. Please discard that as it is incomplete. Below is that e mail finished up. thank you.
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Marsha V. Hammond, PhD, Licensed Psychologist, NC
cell: 828 772 5197
RE: MEDICARE code 96152 which wrapped around to NC Medicaid psychotherapy code e.g., 90806, etc.
Date: August 8, 2013
Dear Mr. Tax:
Thank you for contacting me. I KNOW that 96152 is not in my SMC contract. It has NEVER been a Medicaid code. It is a Health & Behavior code, put into use by the American Psychological Association in conjunction w/ discussions w/ CMS in 2000. I have used it for years without the issues that are plaguing me as associated w/ SMC LME.
If I could turn up my old Medicaid RA's, which are now unavailable as Value Options no longer manages any part of NC Medicaid, via the NC webclaims site, I could print them out and send them to you. I do not keep my RA's from previous years.
As I stated before, prior to the LME's taking over Medicaid, this is what would happen when I submitted a 96152 MEDICARE code for dually eligible clients. NOTE: This is not what took place re: MEDICAID ONLY clients. For those clients, I would simply go to NC Medicaid webclaims, submit the (then) 90806 or whatever applicable code and be paid.
NC MEDICAID VALUE OPTIONS AUTOMATICALLY WRAPPED AROUND for the dually eligible Medicare/ Medicaid clients utilizing the 96152 Medicare code. HOWEVER, a different psychotherapy code was applied. I never asked why. I simply got paid.
I have contacted as per this e mail Dr. Bert Bennett of NC Medicaid, a psychologist working in Raleigh w/ Behavioral Health to see if he can advise you about this matter. I have no idea how to contact Value Options and reobtain my RA's so you understand that this is how things occurred for years prior to the LME's taking over NC Medicaid.
96152 is the most appropriate code for me to use as I interface w/ physicians, psychiatrists, etc., to provide integrated care for my patients who commonly have overlapping medical and mental health issues.
I left you a voice mail a moment ago. Thank you for continuing to look into this matter.
Sincerely,
Marsha V. Hammond, PhD
posted by Marsha V. Hammond, PhD at 3:00 PM
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