Valencia County agencies in jeopardy of losing Medicaid funding


Lynne Getchell is scared for a lot of people. And she is scared for herself.

Getchell is one of the 30,000 people across New Mexico in danger of losing access to behavioral health services that are critical to her continued well-being.

Getchell, a Tomé resident, has been caught up in the aftermath of a Medicaid fund freeze for 15 nonprofit behavioral health agencies in New Mexico, five of which provide services in Valencia County.

The funding freeze was precipitated by an audit ordered by the New Mexico Human Services Department that claims more than $36 million in Medicaid funds had been erroneously or fraudulently paid to the 15 providers during the last three years.

Medicaid payments were suspended, as required under federal law, said Matt Kennicott, spokesman for the Human Services Department.

A consumer at Valencia Counseling Services for more than five years, Getchell says she doesn’t know where she’s going to go if the agency has to close its doors. She said the medications she receives can’t be prescribed by her primary care physician because she is not a psychiatrist.

“I don’t see where the low- and no-income people are going to go,” Getchell said. “I know quite a few people who won’t be able to handle this change. Mental illness is not an easy fix.”

When asked, Getchell said she had not personally experienced any administrative problems at Valencia Counseling that limited her care.

“If some of these places are not following procedures, then make them correct them. But don’t take away services from 30,000 people,” she said. “I don’t understand why they are not giving each facility what its deficiencies are and a chance to correct them. And let’s prove it before we stop funding.”

Sam Vigil, CEO and founder of Valencia Counseling Services, said with about 80 percent of the agency’s funding coming from Medicaid, it was going to be a struggle just to stay open until the end of July.

Valencia Counseling serves about 2,000 clients in three counties.

Vigil said no one from the state has told him what issues the audit revealed.

“We have done a good-cause request to get funding back and we are hoping then someone will come say what we did wrong,” Vigil said. “I asked them when we would know if we got funding back and they said, ‘When we’re done.’”

There was a hearing for an emergency injunction before a federal judge Wednesday morning. The outcome of that hearing was unknown at News-Bulletin press time.

“If we don’t get some relief, we will probably have to begin laying off people before the end of the month,” he said. “Our biggest concern is people on medication.”

Vigil said his counseling service is trying to transition those clients to other agencies, but with many of the behavioral health providers in Valencia County — Partners in Wellness, Hogares and TeamBuilders — in the same boat, that transition is going to be difficult at best.

“We are serving the poorest of the poor who already have a hard time just getting here. Going further is going to be a real hardship,” he said. “Without Medicaid we would probably have to shut down completely, once we transition clients safely to other providers.”

As far as the findings in the audit, Vigil said while there have probably been mistakes made, intentional fraud was “way out of our league. We have been operating for more than 30 years and that has never has been the case.”

He points to last year’s audit score of 92 percent as proof.

“Fraud has never come up,” he said.

Vigil said when OptumHealth took over the behavioral health contract for the state in 2009, his agency was overpaid by about $710,000, which it paid back.

As recently as last year, Valencia Counseling Services paid back more than $100,000 in Medicaid overpayments, Vigil said.

“There are too many unanswered questions and we want to know what we did wrong,” he said. “But nothing like that is coming down the pipeline.”

In a written statement, Anne Martinez, administrative director for Partners in Wellness, said Tuesday her organization has not received any specific information about the situation.

“What I can say is that as recently as last summer we were audited by the state using a rigorous and comprehensive tool, and received scores of 100 percent and 94 percent,” Martinez wrote. “As well and most importantly, our team of dedicated practitioners remain committed to and inspired by all we serve. We’ve made repeated requests to meet with HSD, and we’re eager for them to oblige.”

Marcos Baca, spokesman for Youth Development, Inc., said the agency does not provide any Medicaid services out of Valencia County so local clients should not be impacted by the freeze.

According to a press release, YDI’s funds account for less than 2 percent in Medicaid revenue. During the 28 years the agency has been providing behavioral health services, it has been subject to well in excess of 100 audits, site visits and monitorings from all its city, county, state and federal funding sources, the statement continued.

“OptumHealth alone conducted two separate agency audits in 2012 and found YDI compliant in all areas. One of these audits gave the agency a 96 percent rating,” the release said. “YDI was notified on Monday, June 21, along with the other 14 providers of this pending investigation, but has yet to be provided with any information regarding the claimed mismanagement issues with YDI. YDI will respond fully and expeditiously once the specific concerns leading to this investigation are made available to us.”

Nearly 20 county residents, ranging from consumers to providers, gathered for a brief meeting Tuesday afternoon at St. Matthew’s Episcopal Church in Los Lunas to come up with a plan to combat the funding freeze.

A major concern was the lack of information being released about the agencies’ alleged wrongdoings.

“We want accountability, but this just pulls the rug right out from under the people who rely on this system,” said Fr. Robert Mundy. “And shame on this administration. We are talking about the most vulnerable of people.”

Mundy and others expressed a great deal of apprehension about a group of Arizona companies waiting in the wings to take over administrative duties for the agencies if they should fail to get funding returned.

“For-profits should not be administering public health dollars,” said Kenneth Davis, who works in the behavioral health field. “For-profit companies only differ from nonprofits in two ways: how big that number on the bottom line is and they don’t care how they do it.”

Kennicott, of N.M. Health and Human Services, said the audit was never targeting clinicians, but rather concerns about the providers’ management and billing practices.

There are about 1,500 behavioral health providers in New Mexico, serving a total of about 85,000 consumers, Kennicott said, all of which receive Medicaid funding to some level.

“These 15 serve about 30,000 of the most vulnerable and difficult to treat consumers,” he said.

OptumHealth is the managed care organization hired by the state to manage behavioral health care and the accompanying Medicaid billing. It upgraded its program integrity system in early 2012, Kennicott said.

Kennicott said in the past, suspicious instances that were turned over to HSD sometimes turned out to be simple billing errors or sloppy bookkeeping. The state was able to take corrective action and work with the providers, he said.

However, Kennicott said, last year, there were some very unusual red flags on some of the providers in Optum’s program integrity system. The company came to HSD which in turn brought the state attorney general’s office into the loop, Kennicott said.

A firm out of Boston, Public Consulting Group, was hired on a $3 million contract to audit the providers further and either confirm or negate the concerns raised by Optum.

“PCG came back and said they had some really interesting findings,” Kennicott said. “They went through all 15 providers and they all failed the audit.”

The full audit is not available because it is part of a criminal investigation, Kennicott said, but an audit summary was released by HSD.

“When HSD examined the case files which impact health and safety of individual consumers, a more than 57 percent error rate was discovered,” the summary reads.

“We’re not saying everyone here committed outright intentional fraud,” Kennicott said. “But we threw out the oops-es and there are still a lot there. Even if it wasn’t intentional, we still have to bring it to the AG.”

The allegations in the audit summary range from fiscal mismanagement all the way up to issues that may have directly contributed to the death of two people. The agencies are not identified in the summary, so there is no way to know where these incidents took place.

In a 2012 case, an inpatient psychiatric facility did not follow its policies of keeping all suicidal-tendency consumers in line of sight, instead checking in on the consumer every 15 minutes. The consumer committed suicide in the facility, the summary says.

Another finding alleges that a CEO and family members were paid as much as $1.5 million as annual compensation for services and related transaction, according to the summary.

Now that the AGs office has accepted the case, Kennicott said the state is required by federal law to freeze Medicaid payments to those providers.

In cases where the providers had multiple offices, Kennicott said payments were suspended for the entire agency, not just one office.

The agencies can get funding back under what is called a “good-cause exception,” he said. The provider must provide evidence as to why the payments should come back and HSD and the AG’s office will review the written request.

“For any of these organizations, we would set a list of criteria they need to meet for funding to be turned back on,” he said. “If need be, if providers through good cause either cannot accept the terms or feel they can no longer continue services, we have provider agencies on standby in Arizona so set up management structures so the clinicians can continue services.”

The state has reached an agreement with several Arizona companies for payments of up to $17 million for management services. Kennicott said that $17 million was a ceiling on the contract.

“We are going to be keeping a very close eye on that,” he said.

Medicaid payments were suspended for the following behavioral health agencies:

*Teambuilders, Inc.
*Partners in Wellness
*Presbyterian Medical Services, Inc.
*Hogares, Inc.
*Youth Development, Inc.
Pathways, Inc.
Border Area Mental Health
Counseling Associates
Families and Youth, Inc.
Southwest Counseling Center
The Counseling Center
* Valencia Counseling Service
Southern New Mexico Human Development
**Easter Seals El Mirador
*Service Organization for Youth, Inc.

*These agencies provide services in Valencia County.
**These providers have had all or some of their Medicaid funding restored.

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