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Medicaid bureaucracy pinching some NC group homes

Posted January 29, 2013

— The operators of adult group homes across North Carolina report increasing delays in the Medicaid reimbursements that they depend on to keep their doors open.

The delays result from a combination of a new billing system the state implemented this month and a growing backlog of appeals by people seeking to retain their Medicaid coverage under new eligibility rules.

As of Jan. 1, group home residents were no longer eligible to receive Medicaid payments for personal care services, such as assistance with bathing, feeding or other daily chores. Federal regulators pushed for the changes to ensure the same personal care eligibility standards exist for people no matter where they live, instead of having rules that may steer people toward institutional care.

The new eligibility requirements came with new Medicaid billing forms that operators say are more complex, and some providers aren't filling them out correctly or completely. That means their reimbursements are held up until the paperwork errors are fixed.

"No one really knows what's going on and what we should do about it," Jenny Gadd, manager of Booth Road Group Home in Chatham County, said Tuesday.

Phone calls to state and federal officials haven't helped, Gadd said.

"Our jobs are extremely challenging before we even get into the paperwork and appealing for services. It's an extra challenge that doesn't help us serve our clients any better," she said.

Last week, state officials said the operators of a group home in Montgomery County simply packed up their computers and left after telling officials that delayed Medicaid payments would force them to shut down. Local officials were able to find new residences for the more than 40 people in the home.

In addition to the paper maze, appeals for Medicaid coverage also have bogged the system down.

Medicaid paperwork Complex Medicaid paperwork latest challenge for NC group homes

The Office of Administrative Hearings has received about 15,000 appeals this month from people seeking to re-establish their eligibility for personal care services. Fewer appeals were filed in all of 2012, officials said, noting about one-third of the January appeals have been processed.

Once appeals are registered, residents can continue to receive Medicaid coverage until their appeals are heard.

Gadd said her group home hasn't been able to file appeals yet, and the deadline is Thursday.

"We had our assessment the day after Christmas, but we have not gotten letters (from the state required for an appeal)," she said.

Every delay makes it harder to remain open and serve the people with mental illness and developmental disabilities who live there, she said.

"It's 30 percent of our revenue," she said of the Medicaid funds. "You can't take that hit and stay open."

Alex Harrison, a group home resident who suffers from schizo-affective disorder, said he depends on the home's staff and fellow residents to monitor his medications and help him with everyday living.

"I need to be in a group home. I can't make it on my own," Harrison said.

The state Department of Health and Human Services is trying to train providers on how to complete the Medicaid forms and to process the appeals to get reimbursements processed faster, department spokeswoman Julie Henry said.

"We have already resolved many of the claims rejected due to billing confusion," Henry said in an email to WRAL News. "Our primary concern remains the individuals residing in these facilities and that they receive the care they need in the appropriate setting."

DHHS freed up about $1 million to help residents stay in the group homes through the end of January, and lawmakers said they hope to have a bill through the House by next week to resolve the Medicaid funding problems group homes face because of the changed eligibility requirements.

9 Comments

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  • maybelle Jan 30, 5:46 p.m.

    A lot of these people used to live at Dix

  • Mister Jay Jan 30, 5:01 p.m.

    HOw many people are in the home? Most long care places do not have NEAR enough people working to take care of the number of patients. It is entirely possible this one person is handling fewer people than the nursing homes handle.

    First of all, more than 5 or so people are in the house. They rotate in and out. It is not a long-term care facility (nursing home). These are developmentally challenged persons who probably work for prisoner wages making light bulbs.

  • whatelseisnew Jan 30, 3:26 p.m.

    "The (not) funny thing is some of these group homes are scamming the patients they are supposed to care for. Owner bought a house next to mine. One lady lives there around the clock. Every morning a dilapidated van loads up everyone and they go off to somewhere. Then come back. One woman cannot care for that many people."

    HOw many people are in the home? Most long care places do not have NEAR enough people working to take care of the number of patients. It is entirely possible this one person is handling fewer people than the nursing homes handle.

  • whatelseisnew Jan 30, 3:25 p.m.

    "Now neither group is covered. NC lawmakers could have covered both groups, but chose to cover neither."

    It is not the lawmakers that cover ANYONE. It is the taxpayer. The money does not exist. this is what happens when people are dependent on GOVERNMENT for their well-being. I certainly hope this State is not dumb enough to expand Medicaid. It already can not pay for the current program. Now that amnesty is about to happen for the illegals, this program will have many new people on board.

  • Mister Jay Jan 30, 1:37 p.m.

    The (not) funny thing is some of these group homes are scamming the patients they are supposed to care for. Owner bought a house next to mine. One lady lives there around the clock. Every morning a dilapidated van loads up everyone and they go off to somewhere. Then come back. One woman cannot care for that many people. When do I see the owner? When she pulls up to the mailbox every now and then in her Lexus SUV. But this is an improvement. It used to be there with no vehicle there around the clock. The old van came by and picked them up...now it stays there. Bilking the medicaid system to live in luxury. And this in not the only time I have seen this. I know you have too. Share your stories. For every good home there is probably 3 bad! Sad, sad, sad.

  • ncfarmhand2 Jan 30, 1:27 p.m.

    Medicaid changes are impacting therapists as well as group homes. For example, the form to request authorization to treat residents of Montgomery County is approximately 19 pages if you print the form. The current codes for Psychiatric Treatment are not even loaded into the system so it is impossible to request authorization for those services. In addition to this prohibitively lengthy and complicated form to request services, Medicaid has slashed their reimbursement rates. Providing mental health treatment to medicaid patients may be good for the soul but it might not keep your lights on.

  • unc70 Jan 30, 11:41 a.m.

    The rules for what is paid by Medicaid changed January 1. Medicaid no longer pays for personal care help fir those in group homes. It never paid for such services for those still living in their own homes. Those living independently sue to be treated equally. Now neither group is covered. NC lawmakers could have covered both groups, but chose to cover neither.

  • LuvLivingInCary Jan 30, 8:18 a.m.

    the delays are due to the nursing homes beginning to submit their clains directly to that new mmis system that is supposed to be fully online in july.

    so they take the group of medicaid providers that live paycheck to paycheck and have a huge voice and make them convert to the new system first. great insight. dma will write them all checks while the claims catch up. don't worry this will all be hushed up.

  • Terkel Jan 29, 6:46 p.m.

    This is a perennial complaint! When are the clowns at DMA going to do some work, stop fighting among themselves, and get this system in? Even if it means you have to work an 8 hour day.