OFFICE OF THE ATTORNEY GENERAL OF NEW MEXICO MEDICAID FRAUD ELDER ABUSE DIVISION CONFIDENTIAL INVESTIGATIVE REPORT Case Report Supplemental Report Case Name: The Counseling Center Synopsis An investigation was conducted into potentially fraudulent conduct of The Counseling Center. The investigation looked at the Public Consulting Group (PCG) audit, the Optumflealth audit and a referral that came into our office regarding The Counseling Center. The issues raised by the PCG audit are as follows: Inappropriate billing for case closure due to lost contact with client Unqualified staff Billing a procedure code without a modifier Billing for calls to client to remind of appointment Lack of new goals on updated treatment plan Units billed do not match documentation Billing comprehensive community support services that are not face to face or in the community. No discharge criteria on treatment plan No discharge plan included with treatment plan No estimated discharge date on treatment plan No documentation for date of service billed or more units billed than documented Assessments do not contain appropriate axes (there are five axes from the Diagnostic and statistical Manual of Mental Disorders which are different diagnoses) team not listed on documentation Some of these issues were able to be resolved without a field investigation. Most of the unqualified staff issues were resolved by reviewing the credentialing files and speaking with the PCG staff. For example, numerous claims were failed due to therapist I klavwv Rwlactroi not being qualified to provide rehabilitation services. We carefully reviewed the credentialing file for and found that he had a bachelor's degree, had more than two years required relevant experience and had received 20 hours of comprehensive community support service training within 30 days of credentialing. Therefore he met the requirements to perform both comprehensive community support services and to be an on site team leader for rehabilitation services. For those services billed without a modifier rehabilitation) we found no Page I of 5 difference in the rate of pay with or without the modifier so the provider received no additional funds for these billings. We were able to view the treatment plans in the office to determine whether they contained a discharge date, discharge criteria or a discharge plan. We found paperwork for most of the missing documentation so that there did not appear to be a pattern of billing without supporting documentation. FGDAJQO I, Policy Staff Manager with the Program Integrity Bureau with Human Services Department, was instrumental in answering our questions regarding the axes needed for assessments. For the other issues we traveled to Alamogordo to interview staff and request more documents. That investigation is described below. The resulting amount of failed claims that we agreed with totals $5,264.24. (See Exhibits A and investigative report) Issues raised in the Optum audit as of June 2013 are: Unbundling of intensive outpatient therapy services. Billing 90806 on the same day that 90862 is billed. Upcoding therapy services to 90808. Excessive billing of rehabilitation and comprehensive community support services. Billing for services to a client on the same day that the client was seen by another provider. Billing medication monitoring and medication management on the same day for the same client. We were able to resolve the issue of billing 90806 (individual and 90862 (pharmacologic management) by speaking with Policy Staff Manager with the Program Integrity Bureau. She explained that they could be billed on the same day if the person billing the therapy was not qualified to perform the other service. We knew from prior interviews in August of 201 3 that the persons providing therapy were not qualified. This included employees who are therapists that have no medical training. The pharmacologic management was provided by either a or nurse practitioner. For the upcoding issue, we looked at percentages of 90804 (1/2 hour therapy), 90806 (1 hour therapy) and 90808 (1 hours therapy). We found that over 90% were 90806 which is appropriate. Upon review, the allegations related to excessive billing proved to be too vague and lacked the specificity necessary to allow fiirther investigation. All of the remaining issues were investigated through interviews in Alamogordo. Those issues were unbundling of Intensive Outpatient Services, billing for services to a client on the same day that the client was seen by another provider and billing medication management and medication monitoring on the same day for the same client. Most issues had an immaterial amount of claims (1 5-30) except for the last issue which had 428 instances of this billing. See investigation below. A separate referral on The Counseling Center had been received in 2012 in the form of an anonymous letter to this investigator. In the letter the writer listed the following four examples of what they considered fraud taking place at The Counseling Center: Page 2 of 5 1) The CCSS (Comprehensive Community Support Services) employees were ordered by their supervisor, Be DA an?o to sign progress notes and change the time to upgrade them for more time without justification in the progress notes. 2) The CCSS employees were ordered by to see Medicaid clients for 45 minutes but to bill for one hour. 3) The CCSS employees were ordered by to destroy progress notes and assessments and treatment plans to upgrade the time and date. 4) The CCSS employees were ordered by to sign progress notes without seeing the Medicaid clients for more than 1 hour. A workforce report was requested and five current and former employees of The Counseling Center were selected for interview. Phone calls were made to these individuals and two out of the five denied that any of these activities were taking place and another two said that they did not work with . However, the fifth individual indicated that not only were these things being done but that the worst was that they were billing for enhanced assessments but only doing basic assessments. This was investigated by acquiring a random sample of 30 assessments for review. See investigative report. The total amount of the 30 enhancements billed, none of which qualified as "enhanced" is $13,758.94 (Exhibit C). On our second visit to The Counseling Center on November 5, 2013, all staff that we interviewed were told of the above referenced allegations. All of the employees interviewed denied any knowledge that these activities were taking place. Because the original complainant was an anonymous source, we were not able to obtain specific documentation to support these allegations. Background According to the Public Consulting Group audit report, in February 2013, the New Mexico Human Services Department (HSD) contracted with Public Consulting Group, Inc. (PCG) to audit fifteen mental health and substance abuse providers statewide. In 2012 these providers constituted approximately 87% of all Core Service Agency (CSA) spending for Medicaid and non-Medicaid behavioral health services. Using an approach developed and refined through auditing behavioral health providers nationally and tailored to New Mexico's payment rules and regulations, PCG's audit identified more than $36 million in overpayments to these providers over a three year period from 2009-2012. PCG's clinical case file review utilized two different methodologies for each provider: 1) Random sampling of provider claims: Audit of 150 randomly sampled claims that were submitted by the providers. The sampling methodology allows for a statistically valid extrapolation of the findings. 2) Consumer case file review: A review of a full year's worth of case file Page 3 of documentation for selected consumers (referred to as longitudinal claims) These findings are not extrapolated, but can be used to identify deficiencies that cannot be identified when reviewing a single claim. The Human Services Division determined the results of the audit constituted credible allegations of fraud for 15 providers and sent 15 referrals to the Attorney General's Medicaid Fraud Control Unit (MFCU). One of those providers was The Counseling Center in Alamogordo, NM. OptumHealth also provided a report of their audit of The Counseling Center dated June 30, 20l3 with various allegations that needed to be investigated. The Medicaid Fraud Unit had previously received a referral on The Counseling Center with a number of allegations that could not be substantiated by talking to current and former employees. However, one former manager stated that they were doing basic assessment and billing them as enhanced assessments. This referral was folded into the PCG investigation. Conclusion: A summary of significant findings is listed below. I) Inappropriate billing for case closure (CCSS services) due to lost contact with client if there is an active treatment plan. 2) Community Support Worker with only a high school education preparing treatment plans and assessments. 3) Inappropriate billing for CSW calling clients to remind them of appointments if they cannot remember. 4) No discharge plan included with treatment plans. 5) Assessments do not contain proper number of axes. 6) The assessments reviewed do not meet the criteria for "enhanced". 7) No discharge plan contained in treatment plan. As a result of employee interviews conducted at the provider's offices, supplemental documentation reviewed by the investigative team, discussions with staff personnel at the Human Services Department, a thorough analysis of claims review and application of the New Mexico Administrative Code for the payment of Medicaid claims, the investigative team determined that insufficient evidence exists to support a finding of fraudulent activity. However, improper billing practices associated with enhanced assessments totaled $13,758.94. In addition, unqualified individuals rendering services, a lack of documentation and inappropriate billing practices resulted in an amount of $5,264.18. The total amount associated with the above issues, which were found to be supported by the investigation, is $19,023.18. Page 4 of 5 Completed Supcrvisor:_ 1/ .- Director: UK I Closed Date: Date: I If Date: 05 Date: ((10111 Page 5 of 5 The Counseling Center Inc. Clinical Narrative IT Narrative Enterprise Narrative fiifili PUBLIC CONSULTING GROUP State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report (JIWUI) THE COUNSELING CENTER BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March 6 -- 11, 2013 Main Point of Contact at Facility Jim Kerlin, Chief Executive Officer Extrapolated Date of Service Overpayments $612,663 Actual Longitudinal Overpayments $43,137 Total Overpayments $655,800 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate 83% 80% The Counseling Center Provider Scorecard A Fmuztliuurv This scorecard result translates to the following Risk Tier: 2 Significant Volume Of findings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management to improve processes. CONFIDENTIAL Page 296 1% State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLH. Final Report cxour Provider Overview Payer Claims Paid FY12 Claims Paid Audit Period BHSD 940,241 3,054,500 CYFD 47,531 127,226 Medicaid FFS 54,894 200,934 Medicaid MCO 846,1 14 2,934,261 NMCD 18,274 108,625 Other 3,365 115,508 Grand Total 1,910,419 6,541,053 Audit Team Observations 0 Chief Executive Officer Jim Kerlin met the team at the site and an entrance conference was immediately held. Chief Operating Officer Sandra Wilder was also present at the entrance conference and was designated as the team's primary point of contact for data collection. 0 Personnel files and supervision logs were produced in paper format within hours of the team's arrival onsite. The HR director explained the format of the personnel files and the PCG team manually pulled and scanned the necessary documentation. 0 Clinical records were extracted from Anasazi, the organization's EHR system. Due to challenges with electronic transfer of the files, copies of the necessary documents were printed from the system and provided to the audit team in paper format for scanning and uploading. The audit team was not involved with the extraction of files from electronic systems. 0 Counseling Center staff started extracting clinical files on the first day of the audit. They continued to extract files during the weekend, when the audit team was offsite, so that almost all of the files had been provided in paper format by the time of the team's return to the site on Monday. CONFIDENTIAL Page 297 I CT 3 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 An exit conference was held with CEO Jim Kerlin on March 13. PCG reiterated that the onsite presence was for information gathering so no findings would be provided. 0 Clinical Reviewers noted the following general findings: 0 Random Date of Service Claim Review Comprehensive Clinical Assessments were not always provided to deterrninefsupport medical necessity for the billed service. Treatment plans were missing, not up to date, and/or not individualized per consumer. Progress Notes/Recipient Documents were missing, incomplete, and insufficient of necessary information. PCG reviewed one hundred and fifty (150) random date of service claims for July 1, 2009 through January 31, 2013. Below is a table showing the relevant programs that were included in PCG's random audit sample and the resulting findings: Procedure Program Description Cllalltris Claim fllfiihlilf Claims Code Reviewed Reviewed Failed Failed Failed 90804 minutes 7 307 0 0 0.0% 90806 Outpatient--45-50 minutes 22 1,450 0 0 0.0% 90847 Family Therapy 5 393 0 0 0.0% 90853 Group Therapy 14 424 0 0 0.0% 90862 Medication Management 7 508 0 0 0.0% H0002 Behavioral Health Screening 5 248 1 40 20.0% H0015 Intensive Outpatient Program 5 661 0 0 0.0% H0031 Mental Health Assessment 6 1,627 0 0 0.0% H2010 RN Medication Monitoring 14 1,033 0 0 0.0% H2011 Crisis Intervention Services 5 403 0 0 0.0% H2015 HO, HN, 40 2,626 17 803 42.5% CONFIDENTIAL Page 298 A State of New Mexico Human Services Department Behavioral Health Provider Audits PU Final Report GROUP H2017 Rehabilitation 13 1,813 6 803 46.2% T1007 Behavioral Health Treatment 7 792 2 228 285% Plan Update Grand 150 12,234 26 1,373 17.3% Total Specific Random Sample Review Findings For each program reviewed, PCG identified the level of compliance and any specific areas of concern. 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