Judge: State wrongly blocking Medicaid claims over paperwork
Posted March 8, 2013
Durham, N.C. — A judge has determined that a state Medicaid contractor has been improperly denying Medicaid reimbursements to health care providers.
Administrative Law Judge Melissa Owens Lassiter ruled in favor of AHB Psychological Services in Durham, which sued after a contractor for the Department of Health and Human Services terminated it last month as a recognized Medicaid provider.
The contractor, Carolinas Center for Medical Excellence, determined that the claims AHB was filing were completely inaccurate. Under rules designed to combat Medicaid fraud, providers must have an accuracy rate of at least 70 percent.
Hundreds of Medicaid patients rely on AHB for mental health treatment, said psychologist April Harris-Britt. She called the termination arbitrary and erroneous, saying CCME never told her or her staff was what wrong with their paperwork.
"You have to always have a handwritten date beside a handwritten signature. It's in the records policy manual," Crystal Bush, a supervisor for CCME, testified in a hearing this week.
Some of AHB's dates were electronically entered, and Harris-Britt said she was confused by the filing requirements. It wasn't clear which documents were missing or incomplete, she said, noting it could be something as simple as proof of guardianship.
"Wouldn't it be an easier process to tell the health care provider in writing that that's what's missing?" Knicole Emanuel, Harris-Britt's attorney, asked Bush.
"I can't speak to that because this is a process well above my level," Bush replied.
"Do you think it would be easier in your opinion if you sent a letter saying exactly what was missing instead of things that were not missing?" Emanuel asked.
"I don't think it would be easier," Bush said.
Assistant Attorney General Thomas Campbell said none of that mattered, noting that the Division of Medical Assistance, which handles Medicaid claims, "by law and by contract is allowed to terminate the provider for any reason."
Emanuel said the terminations are part of a growing trend statewide over what she calls subjective criteria.
"Dr. Harris-Britt, in order to keep her doors open, was forced to take out a $60,000 loan when the Medicaid reimbursements were not coming in," she said, noting that the state withheld more than $54,000 from AHB over six months.
Another hearing in the case is scheduled for early June.