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Providers getting squeezed out by Medicaid rules

Posted February 8, 2013

The state Division of Medical Assistance oversees North Carolina's Medicaid program.

— A growing number of health care providers across North Carolina are being terminated from the Medicaid program, and they blame state regulators, who they say aren't implementing anti-fraud rules properly.

Cracking down on Medicaid fraud has become a higher priority for the government in recent years, especially after passage of the Affordable Care Act in 2010. Providers say, however, that the state Department of Health and Human Services is getting hung up on paperwork filed to comply with the rules.

"We were being told it had errors that were not explained to us," said April Harris-Britt, a psychologist with AHB Psychological Services in Durham.

AHB was informed Monday that it was being terminated because the Carolinas Center for Medical Excellence, a DHHS contractor, determined that the claims it was filing were completely inaccurate. Providers must have an accuracy rate of at least 70 percent.

A state audit released last week showed that DHHS provided little oversight of Medicaid contractors like CCME, which contributed to excessive administration costs.

DHHS spokeswoman Julie Henry said Friday that the agency is only trying to enforce the anti-fraud rules.

"Having safeguards in place to prevent fraud and abuse in Medicaid is critical to maintaining services for those who need them most," Henry said. "DHHS works closely with providers to ensure that care is delivered, Medicaid claims are accurate and taxpayers are protected."

Harris-Britt's practice has already stopped seeing about 100 Medicaid patients. Pending an appeal, another 250 could soon be out as well.

"These are individuals who struggle with severe and persistent mental illness," she said.

One such patient is 8-year-old Gavin, who gets some form of intense therapy every day for several diagnoses, including post-traumatic stress disorder.

His grandmother, Jamie Kelderhouse, who now has custody of him, said he was abused and neglected, which left him violent, aggressive, impulsive and developmentally delayed. No treatment worked until they were referred to Harris-Britt about six months ago, she said.

"He's now able to sit in a chair. He is now able to start reading," she said. "He's starting to develop some internal control."

Knicole Emanuel, a Medicaid attorney in private practice, said what happened to AHB isn't an isolated case. She said she sees a trend over what she calls subjective criteria.

"In the past two months, it has probably tripled my business," Emanuel said. "This is not fraud. We're not talking about fraud. We're talking about paperwork nitpicking. Paperwork nitpicking is going to make the health care providers fall out of the Medicaid system, and recipients will have nowhere to go."

Kelderhouse said Gavin won't be able to find outpatient mental health services like those provided by AHB.

"He will become a danger to himself and to society, which will lead him to be hospitalized the rest of his life or in prison," she said.


This story is closed for comments.

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  • Caveman93 Feb 11, 2013

    Fraud in a fraudulent system...makes sense to me!

  • driverkid3 Feb 11, 2013

    When they finish with this, they need to look at the recipients that are commiting fraud also.

  • beachboater Feb 11, 2013

    No job is complete until the paperwork is done. I know that the paperwork volume for any medical practice has increased dramatically in recent months and years. I know of medical practices that have sold out to hospitals because the doctors said they wanted to paractice medicine and not do paperwork.

    Situations such as this should lower medicaid costs but at what cost? If the firm was not filing proper paperwork, they need to be notified and assisted if needed. As we all know, government paperwork can be a nightmare.

    Suspected fraud should be dealt with harshly.

  • noel Feb 11, 2013

    I have to agree with claytontarheel. There has been very real abuse by this group of providers and that's the reason for the nitpicking. If less than 70% of the "paperwork" submitted by this practice can be "nitpicked" then the provider needs to get their practice in order. Their paperwork is the documentation to support the services rendered. I understand that sometimes some things slide, but if you're sliding this much you fail.

  • itsnotmeiswear Feb 11, 2013

    Sorry about gavin's issues, but the abuse of the system by these types of clinics is well known. I am 100% behind the enforcement.