Friday, March 29, 2013

NYS and the last second document drop on the early intervention program

If you pay attention to the news you will notice that Governor Cuomo is on a self congratulation tour for an on-time state budget.  However, what is not mentioned in his self congratulation is the systematic dismantling that is occurring with the State's Early Intervention program and the devastation to social service programs that is left in the wake of his policies.

Families need to be aware because as of April 1 there are many providers around the State who are no longer sanctioned to be early intervention providers.  Additionally, for those who have elected to remain in the system, there has been an absolutely dysfunctional last minute document cram to get contracts in place and according to the Bureau of Early Intervention it seems that many providers were not even aware of the whole process.  Some of us have been blogging and talking about this for over a year - but the reality is that apparently there were a lot of providers who were not tuned in and had no idea that this was all coming.  The Bureau of Early Intervention has asked counties to 'get the word out' so that there are no disruptions - and they are reportedly accepting faxed signatures on contracts - hardly the way for a government to be conducting business.

Additionally, the billing and payment system for the entire program has been changed - with virtually no notice to providers and agencies who rely on at least some degree of cash flow to continue offering services for this program.

Look at what your tax dollars buys you: This email instructing providers how billing in the NEW early intervention program will work was sent out at 5:34pm on March 29th.

New York State Department of Health
Bureau of Early Intervention Electronic Mailing List

 Early Intervention Interim Billing and Claiming Process
  The purpose of this communication is to introduce EI Providers to the interim billing and claiming process effective as of April 1, 2013.
This is the first in a series of communications bulletins intended to coordinate EI Provider migration to the new process. The planned set of communication bulletins will include:

 · How to Submit EI Billing after 4/1/2013
 · How to Enter Paper Insurance Remittances/EOB
 · How to Resolve Workable Rejections & Denials
 · How to View the Status of CLAIMS A New Website

A new website has been developed. Access to the billing functionality at this website requires proper login credentials. Those credentials are being emailed to EI providers separately. This website will serve as the focal point for Providers, Counties, DOH, and the interim fiscal process. NYEIS Billing There is no change to enter billing for children enrolled in NYEIS. If a provider uses the NYEIS data entry screens to enter billing, simply continue to do so. If a provider uses in-house software or 3rd party software to electronically transmit billing to NYEIS, simply continue to do so. The interface from NYEIS to the interim fiscal process is seamless. KIDS Billing

For services provided to children enrolled in KIDS, there are three (3) options for entering billing. First, the ability to process a KIDS “disk billing” file has been preserved. Those providers who have been using KIDS “disk billing” can continue to do so. Second, the interim fiscal process will offer an EXCEL template that can be used to enter attendance off-line. Third, web based attendance entry is available at the new website.

Training Details of how to navigate this new website will be depicted in a training webinar. A link to this training webinar will be emailed to providers in the very near future. In the coming weeks there will be webinars on these interim procedures so that the reimbursement process can continue.

This is how little the NYS government cares about this program.  They dreamt up and negotiated and then legislated these changes TWO BUDGET CYCLES AGO and they are giving providers a document dump on how to navigate the new system the weekend before it is supposed to go live - and in actuality there is no training available at all.

Imagine being asked to go to work on Monday but being told that your boss is still developing a mechanism for how and when you are going to be paid.  Don't worry though!  NY State has it all under control!!

Providers hear words like 'seamless' and promises that 'claims will be processed faster than before' but anyone who believes that has obviously never seen a government try to implement a new process.

The unfortunate reality is that there is no trade association to stand up to this nonsense, and the children and families who receive these services are all isolated in their own homes with no central mechanism to communicate to each other or to even really know that all this is happening.  At least with the proposed OPWDD cuts there are vocal advocates and organized groups.  Early Intervention has no such champion.

And that is why the government gets away with it.

To the degree that the Early Intervention system trips through the next several months, I want to tell you who to thank.  Thank your providers, who have blindly signed contracts and are getting last second instructions on how the billing system will work.  Thank your providers for their willingness to stick it out even though they don't really know when they will be paid.

Please save your most special thanks for your government - and show them how much you appreciate their stewardship at the next election.

Tuesday, March 26, 2013

How citizen participation impacts regulation of a profession

I just got back from a meeting where the NYS Office of the Medicaid Inspector General informed a County that there was inadequate documentation of supervision and that a number of claims were therefore ineligible for reimbursement.

At this exit interview I made the following speech to the OMIG auditors:

Thank you for the opportunity to participate in this exit interview.  I have been an occupational therapist for over 25 years and I have experienced many audits from CARF, CORF, JCAHO, NYSDOH, IPRO, and many others. 

Generally when there is an allegation of violation there is also an accompanying citation of the regulation that was violated.  That citation is particularly useful for the provider community because that allows the provider to access the precise information on what is required, and that empowers the provider to offer the information to the auditor.  The information on the alleged violations on lack of adequate supervision are rather imprecise, and as I want to be a compliant Medicaid provider I am asking for some clarification so that I can be sure to provide the appropriate supporting documentation that you require.

The auditor immediately replied and cited 8 CRR-NY 76.6 which can be looked up at this site and which does not include a level of specificity that the auditor was requiring.

Well I appreciate that citation but you are indicating a level of specificity that is not present in the regulation.  In fact, we provided documentation of monthly supervision and in fact all of the daily notes were co-signed, so it is a little confusing what you are looking for precisely.

The auditor interjected that it was HIS INTERPRETATION that the regulation meant that there should be a certain type of documentation and that if he was a parent that is what he would want.

Thank you so much for advising me about what you would like as a parent.  Therapists always appreciate knowing what families would like to see.  However, we tend not to form policy directly based on what some individual might interpret or what would individual might want.  You see, specificity is really helpful because although I doubt that any provider would object to what you are asking for, the fact is that level of specificity is not supported in the regulation you are citing.  When we provide our documentation we follow prevailing regulations, and the documentation that we provided to you is based on the requirements that are ACTUALLY present in the regulation.  In fact, this requirement that you are asking for is a brand new requirement that I have never before heard.  It was not mentioned in the Medicaid Training that was mandated by the State Education Department.  It is not listed in your regulations.  It is not listed in your Medicaid Q&As.  I am sure you can understand our confusion when you are asking for something that we have never heard of before.  We all want to be compliant Medicaid providers, but specificity is rather important, particularly when weighty allegations are in play.

Here I have to cut OMIG some slack, because in fact they are trying to implement some regulations that they did not even write.  In a more perfectly constructed regulatory world there would be more functional communication between the State Education Department and OMIG.  In actuality that doesn't really exist.  Also, supervision requirements have been shifting based on recent laws, so some of the specificity that was being asked for was NOT a requirement at the time of the service delivery in question.

That left the auditor in the position where he reported that he has to consult with State Ed to find out what the supervision requirements are and what was published in the Medicaid Q&As.  Based on information available online for published OMIG audits it would seem that no one has turned back and asked them to provide supporting citation of regulations before.  Either that or Counties roll over and play dead as soon as the bureaucratic hand takes a threatening posture.

I don't know how this will end, but the point of documenting this is so that people understand that if you approach the auditors on their turf and ask them to provide citation of what you are violating, then they really better be in a position to support their allegation.

My best guess is that the rest of the State can expect a Medicaid Alert in the very near future that will even more clearly specify the Medicaid requirements for supervision of occupational therapy assistants in schools.

Friday, March 15, 2013

"We are building the plane while we are flying it."

The New York State Early Intervention Coordinating Council was scheduled to meet a couple days ago but the meeting was cancelled and a subsequent video/teleconference was scheduled for today, 3/15.  The original meeting was rescheduled to 4/18, but that may still change based on member availability.

It is difficult to not be cynical, but did they cancel the meeting to limit participation and comment prior to their 4/1 switchover when NY State takes responsibility from the Counties for administration of the program?  I asked people in the Bureau of Early Intervention in Albany and they told me that they thought that having a video/teleconference would allow more people to participate than if they just had the meeting in Albany.  What they failed to mention was that the new meeting would not be open for public comment or participation.  In other words, today's meeting was a one way communication and propaganda opportunity for the Department of Health.

During the meeting today they spent 2/3 of the allotted time discussing the Governor's proposals for the 2013-2014 budget year.  The NYS Assembly has already rejected most of the Governor's proposals and the NYS Senate has also similarly rejected reform proposals.  Budget negotiations are still ongoing so where this will all end up is still anyone's guess.  We will undoubtedly know more after the weekend and early next week.  I was disappointed that they spent so much time discussing a budget process when immediate and pressing concerns about the State Fiscal Agent and new contracting with the State needed more conversation.

During the meeting today Director Brad Hutton indicated that there were conversations about delaying implementation of the new SFA but he warned of unintended consequences with delays because the Counties have already terminated provider agreements effective 3/31/13.  What he failed to mention is that these actions are a response to LAST YEAR'S budget and that the DOH has pushed off implementation until the 11th hour, so functionally it is the Bureau of Early Intervention's fault that they are trying to cram all of these changes through at the last minute.  In reality, providers have only had a few short weeks to learn that their contracts were cancelled, to try to review the new contract from the State, and to prepare for an entirely reconfigured billing and payment system.  In Director Hutton's words, "We are building the plane while we are flying it."  This is a stunning statement from a public official and in my opinion a direct reflection of a total lack of functional implementation of the 2013 budget requirements.  In a previous blog post I called this a 'planned demolition' and after hearing Director Hutton's comments today I am more convinced that this was an accurate description.

In just two weeks all early intervention provider contracts will be terminated, and the DOH is frantically scrambling to get contracts approved so that children across the State will still be able to receive services on 4/1.  According to Director Hutton it is likely that an interim State Fiscal Agent will be put in place but the DOH is also allegedly prepared to process claims themselves.  Although he acknowledged providers concerns about payments and cash flow, Director Hutton does not demonstrate any clear understanding of the impact of 11th hour implementation.  In reality, some providers are simply not going to contract with the State.  Others will contract with the State but at the same time there is a parallel crunch to authorize providers as 'non-billing' Medicaid providers so they can get paid.  Anyone who has attempted to navigate the OHIP maze of Medicaid approval knows how daunting that can be - so even if providers have contracts there is little chance that many will have their Medicaid approval in time.  Again, this is the direct result of last minute cramming and is an irresponsible way to run this important program.

In a series of less than honest statements, Director Hutton answered questions about payment schedules by indicating that the State would process claims in a rapid fashion and that the first batch of payments would be processed on April 15.  What he does not say is that this only applies to Medicaid and no-insurance cases, and if the provider is not yet Medicaid approved no one yet has an answer for how claims will be processed.  Apparently this is being reviewed by the lawyers, because the Counties are afraid that lack of Medicaid approval will cause payment responsibility to waterfall down to their level - and they don't want that burden!  If you think that the program administrators in Albany and in Counties have any interest in shepherding a functional program for children then you should have been in on this call and listened to them all maneuver so that they could shuffle the fiscal responsibility off to another party.  In all these conversations there is no mention of the fact that providers are leaving the system, that waiting lists are likely, and that children who were getting services on 3/31 really might not be getting them on 4/1.

Based on the information provided, it seems that Medicaid claims (IF the provider is actually a Medicaid provider!) might actually get processed and paid in a timely fashion, if the system operates the way that they say it will.  Again, the devil is in the details, and what they DON'T mention is that commercial insurance will bottleneck this system because claims adjudication for those insurers will slow down the reimbursement process to a snail's pace.  This is perhaps the most ironic twist for providers: it is generally easy to find providers to work in the wealthy suburbs but those cases may actually be the ones that are slowest to reimburse because there is increased likelihood that those families will have commercial insurance.  It is probably not a stretch to imagine that there will be some modest correlation between socioeconomic status and Medicaid eligibility.  Providers will now likely have to consider that working in those wealthy suburbs will come at the price of generally slower reimbursement.  I am very curious to see how this plays out - because if providers opt to accept cases in high Medicaid-concentrated areas, how squeaky will the wheels of those wealthy families be when there are now waiting lists to provide services in the burbs?  Will providers make the link and suddenly be more willing to accept cases in the urban environments?

I  expect that this level of analysis is lost on the Albany widget counters or maybe they know and just don't care.  It is hard to know.

A lot of the success or failure of this early intervention system will now actually rest on the willingness of agencies to float salaries over time and to access credit to make their payrolls if their caseloads are 'burdened' by families in the wealthy suburbs who have commercial insurance adjudication that will gum up the payment cycle.  The days of the small agency and solo private provider are most likely over, at least to the extent that this is what the system was previously built and dependent on.

The sum total here is that the State has boxed itself into reform, had no functional plan for implementing the reform, crammed it all down the throats of the provider community at the last minute, and has no real plan or idea if their implementation is even going to work in two weeks.  The result will be that on April 1 there will be fewer providers, longer waiting lists, and a very unknown billing process and payment system.  The system will lurch along, propped up by those agencies who will fund the madness until the dust settles.  In the meantime, just in case anyone thinks that they have this all figured out, the next round of disaster is being negotiated behind closed doors for the 2014 budget.

Most notable for people who are paying attention, Director Hutton made repeated statements that 'people have misinterpreted our intent' or 'people are misinterpreting the impact of this or that.'  Director Hutton should consider that if there is so much misinterpretation, whose responsibility is that?  His management of these reforms has been a disappointment, and that is really a generous understatement.

That is my blunt analysis.