HSC takeover a déjà vu to behavioral health fiasco

Mary Kay Papen is the President Pro Tem of the New Mexico State Senate and a Democrat who represents District 38. The public should continue questioning the timing of a vote by University of New Mexico regents to change the governing structure of UNM’s Health Sciences Center. These regents, appointed by Gov. Susana Martinez, claim quick action was needed to streamline university operations and create efficiency. To the best of my knowledge, no thoughtful deliberative process involving input from stakeholders and consensus building took place before this major change. I am worried that this is yet another ill-conceived move by public officials that could end up jeopardizing the HSC, a key player in a core segment of the state’s health care infrastructure.

AG investigation clears final behavioral health providers

All 15 of the behavioral health providers that the state Human Services Department cut Medicaid funding from in a controversial action three years ago have now been cleared of allegations of fraud. Attorney General Hector Balderas told legislators Tuesday his investigation into the final two providers found no allegations of fraud. These final two providers are Pathways and TeamBuilders. HSD cut off Medicaid funding to the state’s 15 behavioral providers in 2013, citing “credible allegations of fraud” after the state department contracted an audit with Boston-based Public Consulting Group. Some of the providers shut their doors after the state halted their federal Medicaid funding, causing a shakeup in the behavioral health system around New Mexico.

3,000 more New Mexicans to lose behavioral health provider

Another Arizona-based behavioral health provider is leaving New Mexico, officials announced Friday. In the latest departure, 3,000 patients currently in substance abuse, mental health and other behavioral health programs—mostly in Northern New Mexico—will have to find a new provider in 90 days, according to a report in today’s Santa Fe New Mexican. The newspaper reported that Agave Health, Inc. is leaving the state, the third of five behavioral health providers from Arizona to leave the state since the shakeup in 2013. “Today, Agave is faced with an insurmountable obstacle, and after many months of undue financial hardship and the foreseen rate reductions in Medicaid rates, the board of directors has regretfully decided to close Agave Health,” Dr. Heath Kilgore, chief executive officer of Agave, and Jeff Jorde, president of the firm, said in a statement. Agave Health is the third of the five Arizona firms to leave New Mexico since the state signed contracts with them for more than $17 million.

Company involved in behavioral health shakeup faces suits

The company responsible for oversight of the 15 behavioral health providers that lost funding for alleged Medicaid fraud is now itself facing lawsuits over alleged fraud. OptumHealth faces three lawsuits over alleged malfeasance in its contract with the state to oversee the state’s Medicaid program. Of the 15 companies that the state Human Services Department, citing an audit by Public Consulting Group, said had “credible allegations of fraud” already 13 have been exonerated by the state Attorney General after investigations. It was Optum’s efforts to root out alleged fraud and waste that led to the shakeup. The shakeup included the state bringing in Arizona companies to take over for the New Mexico providers that no longer had funding to continue, some of which have went out of business.

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.

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.