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Judge: State wrongly blocking Medicaid claims over paperwork

Posted March 8, 2013

— 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.

N.C. health, mental health, Medicaid generic DHHS contractor doesn't point out mistakes in claims to providers

"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.


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  • superman Mar 11, 2013

    It is the American way. You learn to do the paperwork that is required just like if you were in college and taking a case. Anytime you fill out a form to get the desired results--it has to be filled out correctly. The "judge" is just dead wrong. Rules are rules. Dont they apply to everyone? Hope she isnt confused when she files her taxes. He needs competent help.

  • Terkel Mar 8, 2013

    Well put, sceeter. There is a manual online that spells out how to fill out a claim. The provider has to take the initiative to read the instructions until s/he is sure how to do it, and to train their staff. The contractors can't be writing individual letters to each provider. Better yet, that expensive and difficult-to-install system ought to kick the claim back with very specific instructions, which would require one of the experts at DMA to do some gruntwork. Problem solved.

  • sceeter Mar 8, 2013

    Many MH pros, that I've worked with, decide that the paperwork is too annoying or time consuming to complete & only do 1/4-1/2 of anything with it or they have someone else in their office generate it for them (they just sign.). It is the last thing focused upon, though very vital to funding/pay.

    I always say to MH pros that the paperwork is what is seen. If what is seen is full of holes or only partially completed, it makes folks wonder how you are really providing service. See, the paperwork/documentation is "proof" of what you do each day w/the patient & describes why you billed as you did & how you are pd.

    If you want government funds, you follow government regulations & what is required for the chart/paperwork documentation is spelled out in the guide. Yep, there is a "playbook" of sorts that is rather specific.

    Still, it would help though, if DHHS vendors managing the funding, would specify literally WHY they are denying rather than vaguely & in innocuous language.