NC Mental Health Announces Action Plan for Community Support Services

Last month, the North Carolina Department of Health and Human Services announced that is was conducting a review of its community mental illness support services to see if they were being used appropriately. Results of that audit indicate that some providers are misusing the service. DHHS is taking immediate, aggressive action " including recouping payment for services that aren't fully documented, withholding Medicaid payments and referring cases to the proper authorities for investigation of fraud and abuse.

"When we created this new service definition 11 months ago, we said that we would monitor the situation to make sure it was being used as intended," said DHHS Secretary Carmen Hooker Odom. "We now know that some providers aren't using the services as they were intended, or they aren't properly documenting their use. We need to act now to make sure that children and adults with mental illness and substance abuse disorders get the services they need."

Hooker Odom said officials decided to conduct the audit after they found that providers were billing for many hours of community support services, when the service is supposed to be of shorter duration focused on targeted skill-building activities. At the same time, more intensive services were being under-used. "That concerned us," she said. "We believe that some consumers aren't getting the intensive services they need and that increased quantities of this less intensive service aren't going to help them."

Auditors are visiting the 167 providers who were billing for the highest amount of community support services per person served; these providers accounted for the majority of the expenditures on this service. Auditors chose 10 case files at random from each provider and looked at 12 separate factors. The most important factors were: a valid individualized treatment plan, a valid service order, a valid authorization for service and notes detailing the services delivered.

In order for someone to provide these services, they had to be endorsed by the Local Management Entity (LME), which manages, coordinates and monitors the delivery of services in local communities.

"Having these services authorized by one entity that we have contracted with at the state level helped us to identify the problems as quickly as we did," said Hooker Odom. "We will now work with the LMEs to ensure that providers are delivering the services appropriately in the community."

DHHS plans a three-tiered approach to problematic providers:

• Providers that scored 75 percent or more above compliance will have to pay back claims that weren't fully documented, submit a corrective action plan and send one representative to special training.
• Providers that scored 50 to 74 percent of compliance will have to pay back claims that weren't fully documented, submit a corrective action plan, undergo a full record review by the LME, send top management to special training and will have 5 percent of all Medicaid payments withheld until they demonstrate compliance.
• Providers that score below 50 percent compliance will be referred to proper authorities for investigation of fraud and abuse, have their endorsements reviewed by the LME, have all documentation reviewed at the state level, send top management to special training and will have 25 percent of all Medicaid payments withheld until they demonstrate compliance.

In addition to these specific actions for providers included in the audit, DHHS has activities already under way to modify the service statewide. These include engaging in a cost modeling process to reassess the rate paid for the service, work to modify the authorization criteria used to determine if and how much of the service is appropriate for an individual consumer, and tightening the criteria used by LMEs endorse providers to bill for the service. DHHS is also developing additional training on the service definition to make sure providers know how to deliver the service correctly.