Updated on: November 29, -0001

The Land of (Provider Dis) Enchantment

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Original story posted on: April 12, 2017

When it comes to Medicaid providers in the State of New Mexico, providers looking for relief from auditors looking to recoup dollars can count on no help from the state. This is due to a recent bill that Republican Governor Susana Martinez declined to sign into law that would provide some relief.

The beginnings of this bill can be found in June of 2013, when the New Mexico Human Services Department suspended Medicaid payments to 15 behavioral health providers throughout the state. This was based on what the department labeled, at the time, as a “credible allegation of fraud” as discovered by an audit conducted by Public Consulting Group (PCG). In all, the state reported that it found roughly $36 million in overbilling in total from the 15 providers in question.

Approximately one month later, eight of the suspended agencies filed an unsuccessful suit in U. S. District Court to have payments reinitiated, but failed. This led to the shuttering of some of the agencies that had their payments suspended.

Over the next two years, all of the agencies were eventually cleared of wrongdoing, with the few providers whose doors remained open being reinstated, although subsequent state audits did find evidence of some overbilling.

Based on the detrimental effects of the original payment suspension, and the continuing struggles of New Mexico to provide services to behavioral health patients, New Mexico Senate Pro Tempore Mary Kay Papen sponsored a bill that would have given an opportunity for providers the opportunity to review allegations of fraud brought against them, along with the right to respond to allegations either via administrative hearings and in district court.

Governor Martinez had until the close of business this past Friday, April 7th, 2017 to sign the legislation and make it law. She did not sign, meaning that the current lack of rights suffered by providers against which an allegation of fraud is made remains the status quo.

In order to properly assess the detrimental effects of the original payment suspensions to the behavioral health system in the “Land of Enchantment,” it helps to look at the present landscape of behavioral health care.

In order to make up for the sudden shortfall of behavioral health providers in the state caused by the original suspension, five firms from the neighboring state of Arizona were brought in to service the needs of approximately 30,000 patients. Due to an economic downturn in the state, deep cuts in Medicaid payments have taken hold in the interim four years. This caused four of these firms to leave the state. To complicate matters, the handful of providers who survived the original payment suspension and kept their doors open have become gun-shy and are not only no longer seeing Medicaid patients in the state, but have no plans to seek credentials to see Medicaid patients in the future.

While the state reports that access to behavioral health services has increased by 75 percent over the past two years, lawmakers in the state have disputed that number, citing the new financial constraints as a barrier to care.

The state is now almost four years into a saga that has left its behavioral health system in shambles, all because of an overstated, overzealous audit. Without the governor’s signature on this important piece of legislation, providers have lost trust in the state’s Medicaid system as an adequate funding mechanism for the provision of services.

Auditing agencies reviewing services are still not making a clear distinction between fraudulent activities and administrative errors. When this is combined with the lack of due process rights for providers in the state, along with suddenly low reimbursement for services, the ongoing health and welfare of patients across the state is now jeopardized.

New Mexico now stands as proof of the consequences of not allowing providers adequate rights to address allegations of payment irregularities.

J. Paul Spencer, CPC, COC

J. Paul Spencer is a senior healthcare consultant for DoctorsManagement. Is the national correspondent for Monitor Mondays, the live Internet radio broadcast produced by RACmonitor.

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