June 30, 2015

Medicaid overbilling for provider lower than state originally claimed

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A behavioral health provider had overbilling issues, but nowhere near the level the state originally claimed when it shut off Medicaid funding to the non-profit.

Health MoneyThe Santa Fe New Mexican reported that Easter Seals El Mirador, a behavioral health provider had $127,240 in overbilling. The state originally accused the provider of $850,000 in overbilling.

The state cut off Medicaid funding from the provider, and more than a dozen others, when it found “credible allegations of fraud” in an audit of behavioral health providers according to then-Human Services Department Secretary Sidonie Squier. Easter Seals was cleared of fraud by the office of Attorney General Hector Balderas in January of this year.

At the same time, Balderas released a redacted version of the behavioral health audit, something that the Human Services Department and Attorney General had previously refused to do, citing the law enforcement exemption in the state’s Inspection of Public Records Act. Judges upheld the reasoning.

Earlier in June, Easter Seals was one of three behavioral health providers to file suit against the state. This brought the total number of providers suing the state to seven.

The New Mexican reported on the latest news about the Santa Fe-area provider.

But Nancy Smith-Leslie, the Human Services Department Medicaid director, wrote in recent letter to Easter Seals officials that “based on the documentary evidence” and arguments presented during an administrative hearing this spring, “Easter Seals El Mirador was overpaid in the total amount of $127,240.40.”

Top officials from Easter Seals El Mirador said the Human Services Department arrived at the latest figure by extrapolating that total from evidence of roughly $691 worth of alleged billing errors in seven claims that the service provider submitted for Medicaid reimbursements from July 2009 to January 2013.

Smith-Leslie dated her letter June 24 — the two-year anniversary of the shake-up in which the Martinez administration called leaders of Easter Seals and 14 other behavioral health care providers to Santa Fe to tell them that “credible allegations” existed to show they had defrauded Medicaid out of $36 million over a three-year period.

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