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Linda Rosenberg

Former President and CEO, National Council for Behavioral Health

New Mexico Behavioral Health Fraud Unexplained

July 8, 2013 | Compliance | Comments
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The 15 New Mexico behavioral health provider organizations that have been accused of Medicaid fraud by their Human Services Department have been put in an impossible position. The state has tried them and found them guilty in the press and the patients they serve and the staff they employ are understandably frightened and angry.

The accused agencies have been defunded, meaning they are no longer reimbursed for providing care for the most vulnerable in their communities — persons with serious mental illnesses and substance use disorders. These persons, as well as the staff are worried, demoralized, and uncertain about the future. All as a result of a process that seems to be designed to deflect accountability from the state.

It appears to be a case of guilty until proven innocent. If these organizations — that have served their communities for generations — are guilty of “mismanagement, fraud, waste and abuse,” then doesn’t the state at least owe them, and the public, an explanation of how and why?  Where is the state’s responsibility in all this? How does the state account for the fact that the agencies it has certified and licensed — and whose activities it has reviewed regularly in the past — have gotten away with so-called “fraud” all these years?

When the storm clears, I wonder if the charges will turn out to be documentation errors — serious but not fraudulent or criminal. Behavioral health agencies in New Mexico have to navigate some of the most complex rules and regulations that the state has ever had in place. The complexity has mostly served to increase the chances for billing errors.

According to what is known about the audit, none of the findings reached a “Risk Tier 4” level to indicate “Credible Allegations of Fraud.” Still, all 15 agencies were referred to the Attorney General’s office for further review resulting in Medicaid payments being stopped.

We urge New Mexico officials to expedite the investigation so providers can care for those they serve and work collaboratively with the state to resolve valid concerns. And in the meantime, the payment freeze should be lifted while the investigation is on. Vulnerable people are at risk.