New Mexico State Legislature
Santa Fe
August 2, 2013
Via FedEx,
Kathleen Sebelius, Secretary
United States Department of Health & Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Attention: Paul Dioguardi
Re: URGENT — Request for written assurance that lifting pay suspension will not
jeopardize New Mexico's Medicaid funding
Dear Secretary Sebelius:
On behalf of the Legislative Health and Human Services Committee (LHHS), the
bicameral, bipartisan and statutory oversight committee of the New Mexico Legislature,
‘we write to request your immediate assistance and intervention to prevent the interruption
and wholesale revision of the state's existing behavioral health system by the state's
Human Services Department (HSD) based upon: 1) Section 6402(h) of the Patient
Protection and Affordable Care Act (PPACA)'; 2) 42 CF. R. §455.237, a regulation
recently promulgated by the Centers for Medicare & Medicaid Services (CMS) to
implement Section 6402(h) of the PPACA; and 3) the HSD's refusal to find "good cause
to not suspend" behavioral health payments for 14 of 15 behavioral health providers
(“audited providers") who are responsible for approximately 90% of the state's behavioral
health service billings.
"This section of the PACA amends Section 1903()(2) ofthe Social Security Act to provide thet federal
‘inancfal parteipation inthe Medicaid program wil nat be made for any items or services Furnished by an individual or
enity to whom a State has failed to suspend payments" during any period when there is a pending investigation of a
Credible allegation of fraud, unles the state determines in accordance with federal regulstions that good cause exists
not to suspend such payments
242 CFR. $455.23 provides tat stale Medicaid agencies "must suspend ell Medicaid payments to a provider
after the egency determines there isa edible allegation of fraud for which an investigation is pending under the
Medicaid program against an individual or entity unless the agency hes good cause to not suspend payments or to
suspend payments in whole or in parSecretary Sebelius
August 2, 2013
Page 2
We fear that, within days or weeks, New Mexico's existing and already fragile
statewide behavioral health system will be the casualty of the misapplication by the HSD.
of these new PPACA Medicaid fraud and abuse laws and regulations. Section 455.23 of
Title 42 of the Code of Federal Regulations gives the state executive Medicaid agency
broad discretionary powers to impose sanctions that may put a provider out of business
before any adjudication of wrongdoing, and it gives that same agency a powerful tool to
intimidate those who provide services to Medicaid recipients and stifle any constructive
criticism from this same group.
‘The HSD has apparently determined that the restructuring and regionalization of the
state's behavioral health system weighs against finding "good cause to not suspend"
payments to behavioral health: providers who have long-standing relationships with the
communities they serve, Unfortunately, the HSD's use of new PPACA provisions to
favor out-of-state providers over existing and established New Mexico behavioral health
providers and to reconfigure the state's behavioral health system is a case study in
unintended consequences. The new PPACA laws and regulations giving the HSD
complete discretion to determine eredible allegations of fraud and complete discretion to
grant or deny applications for good cause to lift payment suspensions, with no
corresponding requirement to afford providers with any meaningful or timely hearing
rights or rights of appeal, have made it possible for the HSD to create a statewide
emergency where none existed.
Presumably, the federal government will pay a Medicaid portion of the costs
associated with this restructuring of state behavioral health services. The contracts of the
Arizona providers provide for hourly pay rates as follows.
Executive Director $300
Chief Operations Officer $275
Chief Financial-Officer $215
Manager $200
Associate Manager $200
Business Analyst $200
System Analyst $250
Transition Consultant $250
Clinical Leadership $250
Clinical Trainers $250Secretary Sebelius
August 2, 2013
Page 3
With the possible exception of the clinical leadership position, none of these employees
will be delivering direct clinical behavioral health services. The HSD has stated that it
anticipates spending up to $18 million to "transition" behavioral health services to the
Arizona providers.. See Attachment 1.
To address the current behavioral health crisis and to prevent a similar situation from
reoccurring in the future, the committee respectfully requests that the CMS immediately
provide the State of New Mexico with written assurances that the state's Medicaid
funding will not be at risk or in peril, under the provisions of Section 6402(h) of the
PPACA and 42 C.F. R. §455.23 or any other federal law or regulation, for Medicaid
items provided or services rendered by any Medicaid provider that has been referred to
the attomey general for investigation based upon a credible allegation of fraud
determination during the pendency of the investigation of the provider if all of the
following criteria are met:
1, the state restores funding for services rendered after the date upon which the
provider that is the subject of a credible allegation of fraud determination is
referred to the attomey general for investigation and for services rendered
during the pendency of such investigation;
2. claims submitted by the referred provider undergo prepayment claims review;
3. the prepayment claims review is performed by a firm on the state auditor's
approved list or approved by the CMS; and
4, clean claims approved for payment through prepayment review shall be paid
within 30 days of approval.
Background
‘Approximately one month ago, the HSD placed payment holds on 15 behavioral
health care core service agency providers based upon: 1) red flags raised by a fraud
detection product newly implemented by OptumHealth, the statewide entity for
management of behavioral health services; and 2) a follow-on audit conducted by Public
Consulting Group (PCG). During her appearance before the LHHS on July 3, Secretary
of Human Services Sidonie Squier told the committee that a determination of credible
allegation of fraud was made in a matter of days after the HSD's receipt of PCG's audit
report as to every one of the 15 audited providers, whereupon the HSD referred all 15
providers to the state's attomey general for investigation
On July 3, Attorney General Gary King told the committee that his office had made
no determination as to the merits of any allegations of fraud and would investigate the
refertals. Chief Deputy Attorney General Albert J. Lama has appeared before both the
LHHS and its Behavioral Health Subcommittee to advise that, while the attorney general
has directed additional resources to complete the investigations, it could be months or