Are NYS Medicaid audits improperly destroying care systems?

Follow up to earlier post: http://abctherapeutics.blogspot.com/2013/03/how-citizen-participation-impacts.html

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New York State Medicaid regulations are a dizzying and complex ruleset that most providers in good faith attempt to follow in their care of people who are Medicaid recipients.

There is an appropriately strict set of rules that most people don't disagree with because naturally we want our State monies to be distributed appropriately and we certainly don't want people fraudulently gaming a reimbursement system.

Undoubtedly, there are examples of fraud and abuse that require strong auditing response and hopefully even referral to the criminal justice system.  We have all heard of stories of providers submitting documentation for services that were never provided, or providers claiming all kinds of illegitimate program costs, and even providers creating no-show Medicaid funded administrative jobs for friends and relatives.  These are the kinds of cases that everyone agrees should demand the attention of the NY State Comptroller's Office or the Office of the Medicaid Inspector General (OMIG).  Every right thinking person wants this kind of real fraud ended.

However, NY State does something much more insidious with its Medicaid auditing that often gets lost or misconstrued when these audits come to public knowledge in the press.

In a recent OMIG audit of preschool services I witnessed overzealous auditing practices that threatened community agencies and a County with several hundred thousand dollars of alleged 'fraud' and 'overpayment.'  The issue had to do with complex supervision requirements of therapists and what constituted evidence of said supervision.  OMIG was not satisfied with co-signature of treatment notes and quarterly review; they were demanding a level of face to face supervision that was not actually required by regulation.  Wanting to be a compliant Medicaid provider, I asked them to please indicate exactly where in the regulations this kind of supervision that they wanted was required, and they referenced the NYS Education Law that describes the legal practice of occupational therapy in NYS.  Thankfully I know that law rather well, and was able to point out that what they were claiming was nowhere to be found in the law or the regulations.

Flustered by the evidence, I recall the auditor stating, 'Well, if I was a parent I would want more supervision' to which I was able to reply, 'Although I highly respect what you would want if you were a parent, what you want is not in the regulations and therapists are required to follow the regulations when they participate in the Medicaid program.'

So it wasn't that the therapists were not being supervised - the issue was how that supervision was documented and how frequently it occurred.  Supervision is never a bad issue to visit or even re-visit, but it is beyond the scope of OMIG to put itself in the position of dictating professional practice on whims of what individual auditors THINK should be happening.  Based on all of this information, the agencies and County did not have to make any 'repayments'

Unfortunately, OMIG has made this claim regarding supervision all over NY State, and who knows how many agencies and Counties rolled over and paid the improper OMIG tribute.  THAT is something that requires some investigation.

I revisit all of this because there is another story in the news today about Medicaid 'overpayments.'  I know enough to understand that you can't take the OMIG report at face value as I have some understanding of the OPWDD adult day treatment population.  I have some concerns about these 'overpayments.'

I want to focus on the largest issue, which as reported is lack of physician signature on an overall treatment plan for day treatment participants.  According to the article (linked) it seems that this is the largest issue uncovered in the audit.

This lack of signature could mean several things.  It could mean that there is absolutely no physician oversight and that the UCP of Ulster County is taking random people off of the streets and billing Medicaid for the services that are being provided.  In this possibility, the UCP of Ulster County is intentionally bypassing the requirement for MD authorization because they were hoping that no one would notice their nefarious scheme to defraud NYS of its Medicaid money.

Someone reading the article might come to that kind of conclusion because they know nothing about the structure of UCP agencies, they know nothing about OPWDD, and they know nothing about adults who have developmental disabilities and how services are provided.  I actually know nothing about this particular UCP agency but I would practically bet my life that this couldn't possibly be occurring.

It is more probable that there is sloppy documentation or perhaps systemic barriers to obtaining the authorization in the way that the regulation requires.  Perhaps there was a period of time when the agency did not have a 'medical director' willing to sign off on all of the care plans for these people.   That would have left the UCP in the position of having to ask the community doctors to sign a mountain of paperwork.  As many of these Medicaid participants receive multiple medically related services (OT, PT, Speech, etc.) it is likely that there is a lot of physician oversight of their participation, but maybe it was not documented on the correct form.  Or maybe they could not get the signature within the specified time period but in fact it is there, or many other possibilities.

Based on my own experience, it could just be that the OMIG auditor didn't like the way that the agency was getting physician signatures or did not like that the signature was present on a face sheet instead of an actual document.  OMIG has a history of being overzealous.

Here is the reality that the OMIG auditors and the general public are not considering.  People who attend OPWDD day treatment facilities are extraordinarily disabled.  They have significant intellectual disabilities and there is NO CHANCE that if you met one of these people that you would not be able to IMMEDIATELY figure out that they were disabled.

In NY State we have made a public covenant to provide meaningful active treatment for people who have developmental disabilities.  We made this covenant in response to NYS malfeasance in its care.  That is so we don't allow people to remain locked away in developmental centers in the so-named SNAKE PITS of Willowbrook and other institutions.

Now we have community agencies like UCPs that provide (hopefully) meaningful active treatment that respects the dignity of human beings, despite their developmental disabilities.  How ironic is it that we have NY State through its OMIG enforcement arm acting as some arbiter of justice regarding care of these people?  Why is UCP being threatened with severe financial losses and perhaps shutdown if they have to pay back all of this Medicaid money?  Was that money REALLY ill-gotten - or is this indicative of administrative and technical difficulty with complying with complex Medicaid rule sets?

Listen, maybe a head needs to roll at a UCP if there is a dereliction, or maybe they need to get smacked with a fine or an oversight process, and DEFINITELY there needs to be some more correct understanding of what exactly the problem with the physician signatures is.  However, there DOES NOT need to be a confiscatory removal of funds that jeopardizes the program for these people - who undoubtedly NEED IT - whether the physician signature was on the correct form or not.

Here is the solution to the problem: I propose that for every day treatment program that OMIG shuts down on technicalities and NOT on actual malfeasance, that those individuals in the programs be bussed to the OMIG offices so THEY can provide a day treatment program and comply with all of the technical rulesets.

Does NY State really want to shut down community agencies that provide care to people who have developmental disabilities?  If there is actual fraud and abuse then I have no quarrel - but based on my experience I am very concerned that this has more to do with an ill-conceived revenue generating scheme that is being perpetrated upon the most vulnerable people in our State and on those providers who are attempting to provide care.

People with developmental disabilities need your voice.  Ask your representatives if OMIG is shutting down agencies for real fraud - or if they are just beating upon vulnerable and politically weak groups that can't fight back.

We want OMIG focusing on the real fraud, and we want a legitimate process that ensures regulatory compliance without threatening the care systems of vulnerable populations unnecessarily.