Lawsuit: $14 million in new Medicaid fraud ignored in botched behavioral health audits

A former investigator for one of the country’s biggest health managed care providers is accusing that company of profiting from turning a blind eye to fraud against the state. Karen Clark, who worked as a senior investigator for a branch of UnitedHealth Group from October 2011 through April 2012, filed a lawsuit accusing Optum Behavioral Health Solutions of giving Medicaid payments to reimburse nearly $14 million in false claims by nine health providers. Clark also alleges that OptumHealth took home 28 percent of the wrongly reimbursed Medicaid claims.

OptumHealth is the subsidiary of UnitedHealth that manages New Mexico’s Medicaid dollars. Clark faults OptumHealth of never having a proper system in place to perform her chief task—catching Medicaid fraud. “Optum was not set up to detect the fraud claims submitted by providers,” Clark’s attorney, Maureen Sanders, told NM Political Report.

Grant to help APD deal with those with behavioral health issues

Congresswoman Michelle Lujan Grisham announced that the Albuquerque Police Department will receive a $250,000 federal grant aimed at helping the department in interactions with those who may have a history of behavioral health issues. The grant is designed to help the Crisis Intervention Team work with criminal justice and mental health programs. According to the city, the CIT ” works with people in the Albuquerque Community who exhibit chronic behavior patterns that may pose risks to themselves or others.” According to the press release from Lujan Grisham’s office, the congresswoman increased funding for the Justice and Mental Health Collaboration Program. The program is overseen by the federal Bureau of Justice Assistance. “We need more collaboration to get the appropriate services to people with mental illnesses, rather than sending them to jail,” Lujan Grisham said.

Medicaid overbilling for provider lower than state originally claimed

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. The 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.

Delegation meets with HHS head to discuss behavioral health concerns

Members of the New Mexico congressional delegation met with a U.S. cabinet secretary yesterday to discuss behavioral health issues within the state. U.S. Senators Martin Heinrich and Tom Udall, along with U.S. Representatives Michelle Lujan Grisham and Ben Ray Luján met with U.S. Secretary of Health and Human Services Sylvia Burwell to discuss concerns of behavioral health providers in New Mexico. U.S. Rep. Steve Pearce was represented by a member of his staff. In a statement, all four Democratic lawmakers said they were disappointed in the current state of behavioral health services in the state and that they wanted to see change. Pearce is the lone Republican in New Mexico’s congressional delegation.

Tax cuts, a special session, and the budgetary storm that’s brewing | by Bill Jordan

[box type=”info” style=”rounded”]BILL JORDAN is Senior Policy Advisor/Governmental Relations for NM Voices for Children. He can be reached at[/box]

Since the legislative session concluded without the passage of a capital outlay bill—money for public works projects like building community centers—there have been rumblings about the need for a special session. Amid this din, the Executive Office has indicated that it would also want tax cuts to be considered. A special session should be called, but the Legislature should limit their agenda to passing the public works projects and not even consider handing out more tax breaks. How much more evidence do we need that tax cuts are a failed economic development strategy?

Senate endorses bill seeking to avoid repeat of behavioral health shake up

Nearly two years after a Medicaid funding freeze sent New Mexico’s behavioral healthcare system into a tailspin, the full Senate on Tuesday lent bipartisan support to a bill meant to stave off such crises in the future. Senate Pro Tem Mary Kay Papen, D-Las Cruces, sponsored HB 55, which she said will improve the way the state deals with healthcare providers. Responding to questions from Sen. Gay Kernan, R-Hobbs, Papen said the primary differences between her proposal and the paradigm in which the state’s been operating boil down to a few key words: transparency and due process. Current law, said Papen, “is tilted in favor of state, and it’s calculated to make providers’ responses onerous.”

For example, when the state Human Services Department conducted an audit of 15 behavioral health providers back in February 2013, the results pointed to problems including Medicaid overbilling and possible fraud. The state’s response was to immediately freeze payments to all 15 affected agencies.

Medicaid director moving to OptumHealth

The state Medicaid director is leaving her position to take a job with a private contractor that was prominently involved in the controversial takeover of behavioral health providers that took place last year. The Santa Fe New Mexican first reported the news that Julie Weinberg will be moving to a position with OptumHealth. From the Santa Fe New Mexican story:Mark Johnson, CEO of Santa Fe-based Easter Seals El Mirador, one of the ousted providers, said Weinberg’s move from state Medicaid director to Optum raises ethical questions. “There certainly would be an appearance of a conflict of interest in [Weinberg] going to work for a contractor that Medicaid contracted with,” Johnson said.A spokesman for the Human Services Department says that there is no conflict of interest.No state personnel rules forbid someone in Weinberg’s position from taking a job with a government contractor, a Human Services spokesman said. “[Weinberg] will work as an executive client manager with Optum — not with their health program, but on the IT analytics side of their business,” Matt Kennicott said.