The Lost Art of LISTENING.

Before I launch into what will probably be my last post (though don't hold me to it), I want to introduce you to Raleigh Attorney Knicole C. Emanuel with Williams Mullen and her most excellently well written and legally sound Medicaid law blog. In my humble opinion, anyone who can so eloquently and factually draw a strong comparison and contrast between Shakespeare's "MidSummer's Night Dream" and the Medicaid providers' prepayment nightmare is nothing short of a poetic knight in shining armor (yes, chicks can be knights too - why not?)

Now, on with the show...

So, people keep asking where I've gone? Commenting that they've not heard much from me lately... Well, the truth is, that while I have been known to talk to myself on occation, there are some conversations that really need a active partner for successful dialogue. 

Frankly, I'm all talked out at the moment.

American author and journalist, Ernest Hemmingway was quoted as saying, "I like to listen. I have learned a great deal from listening carefully. Most people never listen."

Stephen R. Covey, author of The 7 Habits of Highly Effective People: Lessons in Personal Change said, "Most people do not listen with the intent to understand; they listen with the intent to reply.” 

Therein lies the problem. Nobody's listening.

Everyone has something to say in this Medicaid quagmire - the MCO's and LME's have plenty to say, providers have even more to say, DHHS and DMA have their say, facilities and group homes have something to say, advocacy groups keep trying to have their say, consultants and lobbyists get paid the big bucks to keep saying stuff, and members of the North Carolina General Assembly always seem to have the final say... and don't even get me started on the recipients and their family members that most everyone seems to conveniently forget in all this. 

Nobody can keep the stories straight, not even (and often, especially) the media, becasue it appears the right hand doesn't know what the left hand is doing while everybody's busy with their own personal diatribes and ass-saving.

Everybody's talking but nobody's listening.

Nevermind all of the asinine bureaucratic dynamics at play in the dirty politics of the NC Medicaid system - the inappropriate friendships, roles, relationships, mothers / daughters / board members, ethical conflicts of interest, and who's scratching who's back. Yep, we know about all that.

There are way too many egos on the line here (not to mention the obscene amount of money invested), meanwhile we continue to rearrange the deck chairs on the Titanic while ignoring the real issues of human concious. That's right, I said it again.

I find that this is especially true of the current political climate in North Carolina... For the first time in just over 100 years, the Republican party has finally won back the driver's seat and they seem to be hell-bent on making up for lost time with issues far more "important" than the welfare of our state's most vulnerable citizens, with such utter nonsense as nipples, fracking, abortion / right to choose, ending size limits for K-3 public school classrooms, teaching about abortion risks in public schools while lifting smoking bans on college campuses, imposing rediculous voting restrictions and flat out denying many the right to vote, slashing unemployment benefits, requiring a 2 year waiting period prior to divorce (ironically dubbed the Healthy Marriage Act), vain attempts to negate the first amendment with a state religion, and arresting peaceful protestors, among other idiocy. 

Handbasket anyone?

What with all that debauchery going on, who has time to worry about the threat of homelessness to residents of NC group home facilities (yet again)? Or whether developmentally delayed recipients and their tired-ass exhausted families have the resources to make it through yet another day, or even if they do - if they are actually receiving the services they are entitled through all this slimey red tape? 

I mean really? Who cares? We're such a small minority of the State's population when compared with the number of citizens who have nipples, for Christ's sake.

And speaking of Christ... Conservative politicians love to use the Bible as a platform and foundation for their arguments and justifications and while I've been known to agree with certain positions, it should be noted that countless infamous American psychopaths (Charles Manson, Jim Jones, Fred Phelps, etc.) have also used the good book as sources of inspiration and justification... just sayin'.

My Christ is not wrathful nor boastful, not judgmental nor unknind, and is not dis-compassionate nor cruel toward fellow man nor the world we live in. In the documented lifetime of Jesus, he exhibited love and compassion to all, even those who sought to destroy him and especially for those who could not do for themselves. 

I believe Christ to be alive in the very essence of our collective being, our hearts if you will, a state of mind we all should strive toward. --A perpetual state of love and forgiveness... a state of grace and joy I witness every single day in my own special daughter, Isabel, and her special peers. 

Where the hell are our priorities?

It's way past time for the North Carolina "powers that be" to start listening more to the people, their constituents and voting public, who must live with, and at times suffer from, the repercussions of their actions and decisions. 

You do NOT know what is best for me and mine; that, I can guarantee you. And I'm certainly not in the minority there.

Perhaps if everyone suddenly, miraculously began to listen more, really listen, and made an honest attempt at understanding one another, as I believe the late Steve Jordan had hoped, we wouldn't require knights in shining armor to mitigate such a shameful Comedy of Errors... though sadly, nothing seems to grab attention these days (and further waste taxpayer dollars) quite like a good ole American law suit, eh?

Hang in there folks.

NC Medicaid Law BlogDisability Rights NCFirst in Families NC The Arc of NCNC Health News 

The NC Outpatient Mental Health Zeitgeist

-----Original Message-----
From: Geoffrey Zeger
To: ncadvocacy
Sent: Sat, Feb 2, 2013 4:34 pm
Subject: The NC Outpatient Mental Health Zeitgeist

NOTE: The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting.......

During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic.

It was an unannounced Medicaid audit.

Many clinicians and agencies knew these were occurring so it was not completely unexpected. At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work - electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.

Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred. Medical records were requested by the auditors and submitted by the clinic. CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say 'we didn't get the records' and be elusive and dodgy. Medical records were re-submitted - hand delivered. Feedback from CCME was that the Treatment Plans did not meet standards. The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO's right over the county border but after much back and forth CCME continued to say they were not in compliance. CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans. (NOTE: The LME/MCO from the nearby county said the clinic's Medical Records per their site review were at a 92.5% accuracy!!!).

Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick. Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.

The clinic was then put on a "pre-payment review" meaning claims for services rendered were not paid until the records were reviewed and approved. 'Pre-payment review' is an unguided process that could take 30 days - the approval of records is based on unclear standards so any clinical services rendered were like the lottery - maybe they'll get reimbursed if someone somewhere says documents meet some kind of unknown standards....or maybe they won't get reimbursed at all.

Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due. Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic 'we can't enroll you' due to the 'pre-payment' status.

With only 3 days of lead time, over 100 clients - some of which were children in foster care or with PTSD or within the Juvenile Justice System - had to suddenly be terminated from treatment and referred to other agencies. Fortunately, the clinic will continue - contracted with the other county LME/MCO and accepting private insurance.

Was this top-down inefficient State bureaucracy? Was this effective Public Mental Health policy? Was there any consideration for how this would impact service provision and the clients? Was this purposeful - intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars? Is this the CCME's way of insuring 'Excellence?'

I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability - we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill). With the laser beam aimed at service providers - purposely geared to finding the smallest of errors in an effort to go 'GOTCHA' the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO. Well what about accountability to our clients? Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?

As a side note, it was rumored - and it may just be urban legend - that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it - but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid - how many claim denials they could find and how much money they were able to claw-back.

Wouldn't this contractual arrangement be considered a kickback?....'the more money you save or make us the more you will get from us?' Aren't kickbacks considered illegal within the Medicaid and Medicare system?

Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) - the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated. When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA. With the implementation of the Medicaid Waiver the list has dwindled even further. Initially LME/MCO's have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of 'outcome measures.' More and more agencies will not be able to sustain. It is presumed that the final goal is to have a few large agencies contracted across the state.

Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities....so, I agree that it is necessary to set clear standards and hold providers accountable... HOWEVER, the zeitgeist is an over-rotation.

Let's see how the pendulum swing, tightening of the noose and reduction of reimbursements is working....

One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it's offices in 2 counties. In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office. What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other 'mom and pop' or 'pop up' agencies were dissolved. Well, it seems like no one is immune anymore.

Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.

Clinicians have no recourse either - 'if you don't like the pay cut then you can always try to find another job...wait...there are no other jobs since everyone else is closing so I guess you are stuck.'

On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid. The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive). Many of these surveyed Psychologists had over 8 years of experience - the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base - these are the providers who know the clients and know the community and know the collateral resources.

I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations. What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.

On February 1st a therapist from NC had an 'opinion' published in the Washington Post called:
"The risk of skimping on mental health funding"
Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:

http://www.washingtonpost.com/opinions/the-risk-of-skimping-on-mental-health-funding/2013/02/01/5cdf8ad4-6ba6-11e2-ada0-5ca5fa7ebe79_story.html

Since you may have to do a free 'Register' with the Washington Post online to see the article, here is an excerpt:

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to the National Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.

When the events at the service delivery level are brought to policy makers' attention, I deeply resent their disregarding platitude of "oh well....we know change is hard." Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions). You don't know how many times I have had to say to clients "....I am sorry but there are NEW Medicaid regulations which will effect you in the following way..." You don't know how many of my colleagues have said to me "....the agency where I was working closed....do you know who is hiring...."). 

Furthermore, I resent the proverbial 'pot calling the kettle black' when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top - DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), "structural flaws," and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).

I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that 'Medicaid Reform' will have a positive result. I hate to be a 'Negative Nick,' but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes...a real word) to the other side....in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts. We shall see.....

I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear how much longer I will be able to provide Medicaid services through my own private practice. More to be revealed.

Please forgive the long ramble. I haven't written for a while and a lot has happened. Feel free to write back with your experiences, thoughts, and or comments.

Geoffrey Zeger, ACSW, LCSW
(919) 286-[ redacted ]
[ email address redacted ]

IMPORTANT: The sender intends that this electronic message is for exclusive use by the person to whom it is addressed. This message may contain information that is confidential or privileged and exempt from disclosure under applicable law. If the reader of this message is not an intended recipient, be aware that any disclosure, dissemination, distribution or copying of this communication, or the use of its contents, is prohibited. If you have received this message in error, please immediately notify the sender of your inadvertent receipt and delete this message from all data storage systems. Thank you.

Ongoing problems with NC's managed care transition, and how to address them

From The Arc of North Carolina

Ongoing problems with NC's managed care transition, and how to address them

In mid-2011, the NC legislature passed a bill that would dramatically change the way the state of North Carolina provides services for people with developmental disabilities, mental illness, and substance abuse (MH/DD/SA) issues. The state would shift from a fee-for-service system to a managed care system.

The Arc originally opposed the move to a managed care system and still has significant reservations about the design. However, the political reality is that managed care is here to stay, and The Arc is committed to ensuring that NC's managed care system effectively meets the needs of people with disabilities.

A year and a half after the initial move towards managed care, we are feeling the impact of the plan’s short-sighted design and hasty implementation. Across the state, many of the entities responsible for implementing the shift to managed care (generally referred to as LME/MCOs) are struggling to make the managed care transition and are behind schedule. The effects of these transition problems can be felt throughout North Carolina.

In Mecklenburg County, the state first found that MeckLINK, the LME/MCO responsible for MH/DD/SA services in the area, had not achieved the necessary milestones to switch to a managed care model by its February 1st deadline. The state then re-assigned the responsibility to implement the new managed care system in Mecklenburg to a LME/MCO already operating under the managed care system, Cardinal Innovations Behavioral Healthcare. This decision meant that millions of dollars of public money MeckLINK spent preparing for the new managed care system would be wasted, and Mecklenburg County would adopt the new managed care system several months later than planned.

On January 23, DHHS, now under the leadership of Governor McCrory’s administration, gave MeckLINK a new target date of March 1st, providing it meets its “readiness benchmarks.” This change occurred just eight days before Cardinal Innovations was to take over.

In the southeast corner of the state, Coastal Care, the LME/MCO responsible for MH/DD/SA services for 5 counties including New Hanover, will miss its deadline to convert to the new managed care system by February 1st. While this came to light recently and details are scarce, for whatever reason the LME/MCO is not prepared to switch to the managed care system on schedule, which will result in a significant loss in savings.

Large overruns and implementation controversies are nothing new to NC’s managed care transition. Starting in January 2011, Western Highlands Network, the LME/MCO that manages MH/DD/SA services in 8 counties in the western part of the state, ran a monthly deficit of over $500,000.

Not every LME/MCO has made headlines with its transition to managed care. Many have made the transition largely out of the limelight, but questions remain about their readiness and the effectiveness of current operations.

Obviously, there have been significant problems with North Carolina’s transition to a managed care system for MH/DD/SA services. Now is the time for state leaders to learn from these controversies and make reasoned decisions about the future of our system, and the people it serves.

The Arc believes problems with the state’s transition to managed care stem from an overzealous rush to find savings, rather than a thoughtful and deliberate approach to system design. The operationally arbitrary deadlines for management entities to convert to the managed care waiver are a key example. Converting to a managed care system is not easy- it is expensive and disruptive. We must be sure that LME/MCO’s are truly ready to begin before they turn the switch.

The struggles of LME/MCOs the state deemed ready to move forward to the new system, including Western Highlands Network, prove that the prior notion of what ‘ready’ means is insufficient and needs to be re-examined. Clearly, LME/MCOs must prepare business systems capable of dealing with the large volume of claims, payments, and calls they will receive. It is also important that they are prepared to implement any new services available under the managed care system, respond to people with disabilities and their families about their concerns, and have a well-trained provider network that understands the intricacies of the new system.

Our system’s focus should be on the needs of individuals it is meant to support and the providers working within the system, rather than dreams of short term savings. Getting it right the first time with a well-measured, steady approach will lead to efficiency, cost containment, and higher satisfaction among consumers, providers, and LME/MCOs.

The Arc believes we must adhere the following basic principles if we are to make this transition to Managed Care successful. 

Stability for individuals served and those who provide the services must be the highest transition priority. No LME/MCO should be allowed to shift to managed care if they are not ready. It should be clear that readiness means the ability to successfully support people with disabilities. 

Decisions about LME/MCO mergers and “assignments” need to be about competency and not about politics. 

Where competing goals exist, the state needs to be clear about which it values more. For example, ‘local public management and ‘administrative efficiencies’ are not always mutually exclusive, but in certain areas they may be. 

All interested parties, including The Arc, must be open to new ideas and approaches surrounding managed care. There is no dishonor in adjusting a plan to meet current circumstances. The needs of people with disabilities should dictate policy, not the established position or ego of any state agency, MCO/LME, private organization, or individual. A real partnership with stakeholders must be achieved if we are going to succeed.

Finding savings within state systems for people with disabilities is certainly laudable, but if the savings mean sacrificing the ability of the system to perform its mission, then they are counter-productive. As the saying goes, buy it right or buy it twice.

Comments

MCO's

We who are involved in all the changes sit back and watch and read all that is occuring. We hear that different MCO's get different PMPM amounts and do not understand why. We hear that LME's can not get it together in the outlined time frame. We watch and read about Western Highlands being half a million dollars in the red for months while the board did not realize it. We hear and wonder how MCO's like Western Highlands have the monies to hire agencies like the private group they hired at the cost of hundreds of thousands of dollars to tell them what they are doing wrong after this State hired Mercer to tell them that and still the Mercer organization is at Western Highlands looking at what they are or are not doing right over a year after they began operating while the private agency is there. Now we hear of Mercer going into other LME's to see if they are ready. Why? We watch Western Highlands fire their CEO and pay an agency thousands of dollars to locate a new CEO. We hear agencies not getting reimbursed in a timely manner over never ending changing requirements. We have watched as agency, therapists and psychiatrist have left Western Highlands and I am sure this is the same for other MCO's and wonder where this State is in thinking of the Best Interest of the individuals that they are to serve while spending monies on things that should have already been in place. What is wrong with this picture? Does anyone wonder why all these monies are being spent on requirements that were supposed to be in place instead of on the individuals that they are to serve. I have not heard of any direct care staff which are the back bone of all this getting anything extra for all their efforts. We are forgetting the reason all these MCO's were started, the individuals that they are Supposed to Serve.

What's New in December

December 2012 news, events, and updates.

• WRAL (SpED) Teacher of the Week
• Important Information regarding the Supports Intensity Scale from a provider / mother.
• Arc NC Action Alert.
• NCGA Meeting Notice: JLOC on HHS, 12/11.
• added to Google events calendar.
• From the Arc NC: Tillis Requests Special Session To Address PCS/Group Home Crisis
• Alliance Behavioral Healthcare Weekly Updates, 11/30

[ What's New Main ]

Important Info. re: SIS

Forwarded to me by a provider / mother...

*Note attachments below.

-----------

The Supports Intensity Scale—SIS—is the new tool used to determine the level of services and supports needed for people on the Innovations Waiver. I have attached a copy of the child version and the adult form (age 16 and up).  Currently, DDTI is scheduling these interviews for about 5,000 people.  If you have not been selected yet, the SIS will be completed before the 2014 plan of care is developed.  

I have participated in one child and one adult interview. It is very different from the NC-SNAP in that the person and his/her family and staff are asked to identify what types of supports are needed in order to accomplish a variety of activities. Specifically, you will be asked to rate the frequency, time and type of support needed for your family member. A same aged, non-disabled person is the point of reference. There are 57 questions in the adult version with more than that for children. Remember that each question has the three component parts.   The first question is presented below as  a sample.

Please pay attention to this interview tool. It  is critical because the budget for your family member’s services will eventually be tied to the SIS outcomes. While you can appeal the results of the interview, it is important that you be prepared for the two to three hour session.  Print the form down and review it. The child form is longer and the document has more description of the instrument, but review it.  Make certain that you take with you the staff person (or two!) who know your child’s needs best. I completed the form in anticipation of my adult son’s interview. He was unhappy with having to talk about himself and he did not make it through even half of the interview before he left. That didn’t bother the interviewer. I also took a list of his diagnoses and medications with me as well and had examples and illustrations.

EXAMPLE:  Using the toilet. 

Compared to a same aged, non-disabled person, what is the frequency of support needed?

O = none or less than monthly

1 = at least one a month, but not once a week

2 = at least one a week, but not once a day

3 = at least once a day, but not once an hour

4 = hourly or more frequently

Compared to a same aged, non-disabled person, what is the daily support time needed?

0 = none

1 = less than 30 minutes

2 = 30 minutes to less than 2 hours

3 = 2 hours to less than 4 hours

4 = 4 hours or more

Compared to a same aged, non-disabled person, what is the type of support needed?

0 = none

1 = monitoring

2 = verbal/gestural prompting

3 = partial physical assistance

4 = full physical assistance

SIS Form Example for Adults

SIS Child Version

CAP-IDD ... this is NOT NC Innovations

From Mary K. Short:

The links to the announcements and guidance are below.  The changes from CAP-MR/DD to CAP-IDD are approved by CMS on 10/1/2012 BUT are not implemented until 1/1/2013.  If you are in an LME that is supposed to convert to an MCO before or on 1/1/2013 THIS DOES NOT APPLY TO YOU (or if you are already on the NC Innovations waiver) because you should be working on the transition to the NC Innovations waiver for your LME/MCO "go live" date prior to or on 1/1/2013.  The Special Medicaid Bulletin is specific about timelines and who is and who is not impacted.

Additionally, this is part of what Doug Sea sent out to providers/case managers.  I know he works with DRNC (Disability Rights North Carolina www.disabilityrightsnc.org) and you should probably contact them if you have questions.  If you are in Legal Services of the Southern Piedmont area (Mecklenburg & surrounding), then contact LSSP at www.lssp.org.

The instructions do not include the right to request continuation of current services as a reasonable accommodation under the ADA. Nor do the instructions provide for the right to a notice with appeal rights if such a request is made and denied. It will be up to advocates and providers to let families know they have the right to submit such a plan and to appeal to OAH if denied if they are at serious risk of institutionalization without continuation of their current services. Please make families aware of this.  

Essentially the same issue will occur for families transitioning to the Innovations waiver on January 1 .  Those 36 counties are also listed in this bulletin.

Here are some other possible specific issues to look for as CAP-DD families transition to the new CAP-IDD waiver (for a short time) and to the Innovations waiver:

A.      if LME doesn’t have adequate provider network, can family continue to be paid to provide home support services?

B.      If rate paid to provider is changing (eg no more enhanced personal care services or enhanced respite) and new rate is inadequate to attract qualified provider for this recipient, can recipient appeal rate reduction/loss of enhanced service?

C.      Does the requirement that  Intensive In home support have a fading plan and the 6 month limit for intensive night services violate the ADA or EPSDT?

D.      Does the restriction on services during school hours violate EPSDT if the child requests personal care (not hab serv) in excess of that limit?

E.       Does child recipient have right to case management in addition to care coordination under epsdt if medically necessary in that case because the LME staff are not adequately trained or don’t do medically necessary work the current case manager has been doing?

F.       Does the LME violate due process by “crosswalking” to new services without explaining right to request continued current service and to appeal if denied?

Mary K. Short
828-632-5888 or 704-451-4144 (cell)

Special Medicaid Bulletin:

http://www.ncdhhs.gov/dma/  (SCROLL down, it's the first bullet point on the left.)

OR direct link to the Bulletin:

http://www.ncdhhs.gov/dma/bulletin/pdfbulletin/1012_Special%20Bulletin_IDD_Waiver.pdf

CLINICAL POLICY 8M:

http://www.ncdhhs.gov/dma/mp/index.htm 

(Clinical Policy 8M ... this is the IDD 8M.  I do not have an answer for how it got approved and posted without an additional comment period!)

10,000 Blog Views! and Counting...

This week, the blog reached 10,000 page views! North Carolinians (and others across the country) are watching - and inquiring minds wanna know...

At the time of the June 16th posting, the blog had reached 5,683 since February of 2012, when first launched. Since that time, the hits have more than doubled from viewers in at least 63 counties across the State of North Carolina and beyond. 

Once more, I'd like to point out that regarding total hits, the number (10,143 as of this posting) reflected to the right of the page (previously located at the bottom) is the correct total of page views since the initial launch of this parent / public information blog back in February of 2012. StatCounter was installed in May, so the data you see compiled via the blog's StatCounter statistics only reflects activity from May onward, mostly because I just haven't bothered to change it. 

Viewers include loads of parents / family members as well as provider agencies and professionals, LME / MCOs, universities and research groups, risk management groups, PR firms, law firms, advocacy organizations, and both state and federal government offices (*although due to the ambiguity of government IP data, it's impossible for a novice like me to know which specific offices nor even agencies are viewing)...

Some of the more interesting regular (and some once or twice) NC viewers include: Duke University, UNC Chapel Hill, UNC Charlotte, the Department of Veteran Affairs, the North Carolina Research and Education Network, Disability Rights NC, The Arc of NC (and various county chapters), NC Justice Center, NC Council of Community Programs, Crossroads Behavioral Healthcare (now Partners Behavioral Health Management), Daymark Recovery Services, Piedmont Behavioral Health, Sandhills Center, Saguaro Management and Accounting Services, Inc. (providing billing, human resources, program development and quality and risk management to human services companies), the Mental Health Association of Forsyth County, Raleigh's Campaign Connections PR firm, and numerous NC Government offices and agencies around the state.

And beyond North Carolina's borders: Kansas Health Institute, Virginia Commonweath University (VCU), Minnesota State Colleges and Universities, University of Georgia, Emory University, DC's American University, FHC Health Systems, Hospice of the Western Reserve in Ohio; Charleston, SC's New Hope Treatment Centers; HMS (a public government and managed-care contracting company); Deloitte, Marsh USA, and Alvarez & Marsal (each being US consulting / risk management firms with varying specialties); Nelson Mullins Riley & Scarborough LLP,  Drinker Biddle, and Hunton and Williams (each are national / multi-state law firms); and yes, even the US Centers for Medicare and Medicaid as well as a few hits from US Government offices in Washington, DC.

Yep, as election season launches into full swing (or sling as is oft the case), the world IS watching to see what North Carolina will do with it's special populations -- even if the usually less-than-enthusiastic main-stream media assignments and focus generally fall short in the real-life, human interest for "those people" and their families - because let's face it, nobody really wants to talk about what they don't understand, especially if it makes them sad... 

The 38th Vice-President of the United States, Hubert H. Humphrey, once said oh-so wisely, "The moral test of government is how it treats those who are in the dawn of life... the children; those who are in the twilight of life... the elderly; and those who are in the shadow of life...  the sick... the needy... and the disabled."

It's one of my favorite quotes and oh-so-fitting... and if you happen to be a quote-y kind of person like me and enjoy wise words, here's another for ya...

"Open your mouth for the mute, For the rights of all the unfortunate. Open your mouth, judge righteously, and defend the rights of the afflicted and needy." --Proverbs 31:8-9

So rest assured North Carolina, Inquiring Minds DO Wanna Know.

And to all the blog followers, the advocates, the exhausted parents, supportive family members; loyal and dedicated direct care staff, Case Managers, and various professionals (our personal community villages) who go above and beyond every day to make our lives possible...  and to all the people of conscious who listen, who care, who try and try again - and who never, ever give up because you know what is right and just and because it's just not in your soul's design to believe that one life is worth less than another... I'd like to take this opportunity to say Thank You!

Oh, I mentioned 63 counties; here they are... Clicking on the County links below will take you to the corresponding State representatives page on the North Carolina General Assembly's website.

1. Alamance County 
2. Beaufort County 
3. Bertie County  
4. Brunswick County 
5. Buncombe County 
6. Burke County 
7. Cabarrus County 
8. Caldwell County  
9. Catawba County 
10. Cherokee County 
11. Cleveland County 
12. Cumberland County 
13. Dare County 
14. Davidson County  
15. Duplin County 
16. Durham County  
17. Edgecombe County 
18. Forsyth County  
19. Franklin County  
20. Gaston County 
21. Granville County  
22. Guilford County  
23. Halifax County  
24. Harnett County 
25. Haywood County  
26. Henderson County  
27. Hertford County  
28. Hoke County  
29. Iredell County  
30. Jackson County  
31. Johnston County  
32. Jones County  
33. Lee County  
34. Lenoir County  
35. Lincoln County  
36. Macon County 
37. McDowell County  
38. Mecklenburg County 
39. Monroe County *voter representation falls under Union County
40. Moore County  
41. New Hanover County  
42. Onslow County  
43. Orange County 
44. Pasquotank County  
45. Pender County  
46. Pitt County  
47. Polk County  
48. Randolph County  
49. Robeson County  
50. Rockingham County  
51. Rutherford County  
52. Sampson County  
53. Stanly County  
54. Stokes County  
55. Transylvania County  
56. Union County  
57. Wake County 
58. Watauga County  
59. Wayne County 
60. Wilkes County  
61. Wilson County  
62. Union County  
63. Yancey County  

To find out who your voting representatives are, visit the NC General Assembly search page.

For more on who's involved and how to advocate, see Speak Up!

NCGA JLOC-HHS Meeting Agenda 9/10

SUBCOMMITTEE ON MENTAL HEALTH

JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON HEALTH AND HUMAN SERVICES

AGENDA

September 10, 2012, 1:00 P.M.,

Room 643, Legislative Office Building

Representative Justin Burr, Co-Chair

Senator Louis Pate, Co-Chair

Introductions and Comments 1:00-1:10
Chairman Burr
Chairman Pate

Review of Law Establishing Subcommittee Charge 1:10-1:15
FRD Staff

Overview of Major Mental Health Reform 1:15-2:00

• Major Legislative and Policy Changes 2001 – Present
  Research Staff

(Presentation will address major changes in the State’s delivery of mental health services, including information on Olmstead/ADA – description, impact on the state’s mental health system)

• Impact on State Facilities’ and Community Psychiatric Hospitals 2:00 – 2:45
  Ms. Laura White, Team Leader Psychiatric Hospitals
  Division of State Operated Healthcare Facilities

(Presentation will address number of people released into the community as a result of reforms/policy changes, adequacy of beds and services; changes in availability of state facility and community mental health beds over this period; state facility and community mental health bed capacity; state facility catchment areas)

• LME Perspective on Impact of Major Reform/Policy Changes 2:45 – 3:30
  Pam Shipman, CEO PBH

Impact of Mental Health Policy on Law Enforcement 3:15 – 3:30
Eddie Caldwell, Executive Director, NC Sherriff’s Association

Committee Discussion/Comments 3:30-4:00

Adjourn

Re Appeals & Due Process from DRNC

Because I do make every effort to assure the information I disseminate for families and other interested parties / agencies is factually acurate, I followed up with the good folks over at DRNC regarding the preceding post, Appeals & Due Process (or Lack There Of), so see if there had been any changes since my last missive was sent and posted which included due process concerns...

Below is the response I received:

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From: Jennifer Bills
Sent: Friday, August 24, 2012 11:37 AM

The post is not inaccurate, especially if you read to the end about the status of Final Agency decision-making; however, Elizabeth and I consulted and feel that the tone is far too pessimistic.

Our response post would be:

Document, Document, Document

Medicaid recipients have a decent track record, both when they are represented by counsel but also pro se, of prevailing in Medicaid appeals. The key is to obtain and provide adequate documentation of the medical necessity of the service, and specific details regarding the amount of hours the individual needs. Understanding the criteria used to evaluate requests for services is particularly important. Decisions can only be based on sufficient evidence of the precise amount and type of Medicaid service that is medically necessary for the individual. Appeals should focus on the individual’s medical and social needs, as opposed to the family’s needs, even when families are providing the care. Although hardships to a recipient’s natural supports may provide context for an appeal, that alone may not meet the criteria in the service definition. Letters from clinicians, social workers, direct care staff, case managers or community guides, and families are essential to justify services. Additionally, documentation from medical providers, or a log of behaviors created by the family or direct care staff, may be more persuasive than testimony based on recollection or memory.

Even at the Reconsideration stage, if you provide additional information supporting the request, there is a chance of getting a different decision. Although OAH is not yet making the final decisions, the State legislature directed DHHS to submit a request to CMS to grant OAH this authority, and that process is ongoing. Many cases settle during the appeals process, and cases rarely go all the way to Superior Court. OAH rules allow mediators and judges to assist pro se clients with navigating the appeals process. Although they are neutral and not advocates, they help ensure the process is fair. Our message would be: don’t give up on due process. Rather, utilize it and win!

And it would be great if she could add a link to our MCO Medicaid Appeals fact sheet, attached here.

Jennifer Bills, Senior Attorney

Disability Rights North Carolina

Champions for Equality and Justice

Disability Rights NC is the state's protection and advocacy system. DRNC is a 501 (c)(3) organization. If you are a state government employee, you can support Disability Rights North Carolina through the State Employees Combined Campaign (SECC). Please use code # 1544. Donations support our efforts to promote a clear and independent voice for North Carolinians with disabilities.

Appeals & Due Process (or Lack There Of)

I try very hard not to post a great deal of personal commentary. Though today I just couldn't help myself...

The North Carolina Department of Health and Human Services reached a settlement agreement with the US Department of Justice yesterday (8/23) regarding the State's ADA and Olmstead violations surrounding the improper placement and warehousing of mentally ill and developmentally disabled adults in adult care / nursing homes across the state. [ read more... ]

It is a victory. --However big or small it may seem is moot; it is nonetheless a victory in the recognition of a tremendous need and an acknowledgement of individuals deserving of a quality life and community interaction. Definitely a step in the right direction and I commend everyone involved for their diligence and efforts toward a just resolution.

Not to rain on the parade, but...

What continues to be of concern however, is that while we scurry to "deinstitutionalize" one vulnerable population and invest in services and programs to assure these individuals are properly supported in community environments as they are entitled, we are failing to bolster all the many thousands of other special populations who are already living in integrated settings, be it at home with their families or in supported living, etc. -- the ones who are not institutionalized and don't want to be -- whose loved ones desperately want to keep them in their homes... And yet, it seems that the very supports that allow that to happen, that they also are entitled to, continue to be trimmed away.

It's the human shell game: while we move one population toward community stability, we are pushing much of the rest, slowly but surely, straight into crisis. 

Without proper supports and proper funding for those supports, the reality is that many families will be forced to make the hardest decision of our lives - surrendering our loved ones to the state either because we will have to quit our jobs to provide full time care or we just cannot physically nor mentally do it anymore because we're already hanging on by a bare thread or both (which puts us right back where we started from and begs to question: where will they go? Can't put 'em in nursing homes, that's how we got into this mess to begin with.)

I had an exchange today with a weary and frustrated fellow mom in the eastern part of NC who is about to embark upon the grueling appeals process fighting for proper services and supports for her adult DD children that her family depends upon for their very existence. 

Yes, I said existence - not just the quality of life, certainly not for convenience and most definitely NOT for financial gain; EXISTENCE.

Like filing an appeal because services for your DD child(ren) are being drastically decreased and you simply cannot make do with less because you already are.

Through this dialogue I realized that the critical issues surrounding Medicaid appeals for DD recipients and Due Process, or lack of, are still not understood even on a basic level and misinformation continues to circulate.

Unless something has changed since June 2012 when I sent out and posted my Open Letter and Outline of Critical Medicaid Waiver Issues (with supporting documents), there remains NO FAILSAFE CONSTITUTIONALLY PROTECTED DUE PROCESS APPEALS PROCEDURE for Medicaid Waiver recipients and families! 

If something has changed, someone please let me know; I will be thrilled to update.

Otherwise, currently this is the way it works - or doesn't, as the case may be (from the outline):

What do we know about the Due Process / appeal procedures under the new 1915(b)(c) Medicaid Innovations managed care plan?

• The current appeals process reflects a consumer appeals process to a unilateral hierarchy with no third-party authority to fairly referee.
• As outlined in the PBH brochure and 2012 Provider Manual (pgs. 62-67) is as follows:
• If consumer caregiver has recipient service hours and / or benefits reduced, suspended or terminated,
• consumer caregiver will receive a letter 10 days prior to changes via US Certified Mail a letter, outlining instructions to request a ‘Reconsideration Review’ through PBH (or respective LME/MCO)’s ‘Reconsideration Review Process’ within 30 days of notification.
• If Reconsideration Review, does not yield a response in favor of consumer, consumer caregiver can appeal to both DHHS and the Office of Administrative Hearings (OAH) by filing a request for a State fair hearing within 30 days.
• Once appeal is processed, consumer caregiver may participate in an informal attempt to resolve the conflict through the Mediation Network of North Carolina;
• if the conflict cannot be resolved in mediation or if consumer declines mediation, the matter will be set for hearing before an Administrative Law Judge (ALJ) at the OAH.
• The ALJ will hear the matter and evidence and make a recommendation regarding the consumer’s matter and forward the decision to DMA,
• where DMA will review and make a final decision.
• What’s the point? More time and State financial resources wasted.
• The only recourse following a final decision by DMA is for the consumer to retain counsel and file suit in Superior Court - an extraordinary expense of tens of thousands of dollars that the vast majority of consumer families, including mine, could not afford.
• It should be noted that under the new PBH model, service eligibility for DD Medicaid Waiver recipients is determined by the Supports Intensity Scale (SIS) which arguably provides a more detailed client pictorial, however, the formula specifics which equates a recipient’s level of need by the State’s representative LME is deemed “proprietary information’:
• LME representatives are required to sign and enter into a “Non-Disclosure Agreement” with PBH to protect the SIS methodology.
• This non-disclosure further prevents a fair an adequate appeals process for consumers as how can one effectively challenge information which is withheld from them?
• Proprietary information as such held by an agent of the State providing public services to citizens on behalf of the State - services which are funded by Federal and State monies is, in fact, a conflict of interest.
• This is NOT transparency and only perpetuates mistrust.
• Also noteworthy: PBH recently had a federal lawsuit against acting NC DHHS Secretary Delia and Mann [5:12-CV-46] suing to not only remove final decision-making authority from the State government entity who is to oversee and govern the managed care operation and all LME’s, but to seemingly assure totalitarian authority.
• It is my understanding that this case has since been withdrawn.

OAH, ALJs and the Regulator Reform Act of 2011.

• NC SL 2011-398, commonly referred to as the Regulatory Reform Act, became State Law July 25, 2011, granting final authoritative ruling to OAH / ALJs over Medicaid cases, effective January 1, 2012 and applies to cases contested after that date.
• SECTION 32. G.S. 108A-70.9A(f) reads as rewritten: "(f) Final Decision. – After a hearing before an administrative law judge, the judge shall return the decision to the Department in accordance with G.S. 150B-37. The Department shall promptly notify the recipient of the final decision and of the right to judicial review of the decision pursuant to Article 4 of Chapter 150B of the General Statutes."
• SECTION 33. G.S. 108A-70.9B(g) reads as rewritten: "(g) Decision. – The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision and send it to the parties in accordance with G.S. 150B-37."
• Despite the January 1, 2012 effective date for OAH final authority over recipient disputes in Medicaid matters, federally-funded Medicaid Waiver programs by design have a “single agency rule” which dictates that a single state agency makes final decisions in Medicaid issues which is somewhat conflicting given the design of the new statewide managed care waiver, therefore Centers for Medicare and Medicaid Services (CMS) must grant an exception waiver to the State of NC to permit alternate authority. Currently, NC governing officials and other interested stakeholders are working toward mutually agreeable waiver submission terms, though to date, an agreement has not be solidified.
• Thus there remains NO appropriate fail-safe due process for recipients and families save the unrealistic and unfeasible hardship of unnecessary legal expenses and lengthy court battles.

So essentially, if you disagree with an LME's decision regarding Medicaid services / supports, you pretty much are appealing to the person who instructed the decision to be made in the first place. If that doesn't work out, you can opt to undergo mediation and have a hearing before an ALJ who will then advise DMA of their opinion, but ultimately DMA still has final say.

The confusion seems to come from in between the State Law and the federal hang-up with CMS. 

Yes, NC State Law 2011-398 does in fact grant OAH final decision making authority BUT because of the federal "single agency rule," CMS must have a specific waiver from the State of NC in order for the federal government to allow another governing entity (e.g. OAH) to make decisions which affect federal monies. 

If North Carolina officials cannot agree on the waiver language for exception and this exception waiver is not submitted and approved by CMS before the final implementation of the statewide 1915(b)(c) managed care waiver, the period for appeals will have been exhausted and we may all be stuck with whatever decisions are made for us.

If you are in an appeals process, keep your representatives and advocacy groups informed - and as always, feel free to forward to me anything you wish to share.

*Update : More on Appeals and Due Process (feedback on this post) from Disability Rights NC.

FW: National Core Indicators Adult Consumer Survey

Below is an email I received regarding the National Core Indicators (NCI) surveys and reports conducted as a collaborative effort between the National Association of State Directors of Developmental Disabilities Services (NASDDDS) and the Human Services Research Institute (HSRI) as pertaining to the Durham Center LME (now Alliance Behvioral Health Care).

From the NCI website: 

The purpose of the program, which began in 1997, is to support NASDDDS member agencies to gather a standard set of performance and outcome measures that can be used to track their own performance over time, to compare results across states, and to establish national benchmarks.

• NCI State Report for North Carolina, 2009-10 data
• For comparison, you may view reports from the other 29 participating states here
• NCI Adult Consumer Survey Outcomes, North Carolina Durham LME Report, 2009-10 data

Currently, my daughter is 14 years old and personally I have never received a survey of any kind from any state nor federal agency regarding services she has received over the years that I can recall, nor have I ever been asked for my opinion nor feedback, though I'm certain it's no surprise to anyone who knows me that I happily provide it anyway. 

But apparently some folks are asked for input on their experiences. 

-----------

Subject: FW: National Core Indicators Adult Consumer Survey

DMHDDSAS conducts National Core Indicators surveys of people with intellectual / developmental disabilities (IDD) through the Division's Core Indicators Projects annually. The surveys consist of (1) family surveys that are mailed to the family members or guardians of random samples of people with IDD who received a service other than case management or care coordination in the past fiscal year and (2) the adult consumer survey. The latter consists of two parts: (a) the background information section that is completed by a service provider, and (b) the adult consumer section that is completed through a direct interview of the person with IDD for the first part of the section and a direct interview either with the person with IDD or with others (e.g. a family member or an advocate, or a service provider).

Attached is your advanced copy of a report about the performance of your LME/MCO on the national core indicators (NCI) that was produced by the Human Services Research Institute (HSRI) based on the adult consumer surveys conducted in SFY 2009-2010. HSRI is a non-profit agency that works with states on measures that impact people with Intellectual and Developmental Disabilities (IDD).

HSRI analyzes NCI data and publishes reports that show how each state performs against other participating states. The final report for 2009-2010 for the state of North Carolina may be accessed at the following HSRI website: http://www.hsri.org/files/uploads/publications/NCI_CS_09-10_FINAL_Report.pdf. DMHDDSAS will be publishing LME-specific reports on its own website on or before the end of this month.

We believe that the findings generated from the NCI surveys are extremely valuable for improving the system at the state and local levels and we hope that you will share them with your stakeholders, including members of your Community and Family Advisory Committee (CFAC).

If you have questions about the report or the project, please do not hesitate to get in touch with Maria Fernandez (919-733-0696; maria.fernandez@dhhs.nc.gov).