Health Public Focus. Proven Results.? New Mexico Human Services Department Behavioral Health Provider Audits Final Report CONFIDENTIAL June 21,2013 rill 148 State Street, Tenth Floor, Boston, Massachusetts O2l Tel. (617) 426?2026, Fax (611)426-4632 com PUBLIC GROUP Publ Consulting Group. inc 5 an Affirmative ActionIEqual Opponunily Employer ?k State of New Mexico II I Human Services Department BahaVloral (.Itoul' Executive Summary EXECUTIVE SUMMARY In February 20l3, the New Mexico Human Services Department (HSD) contracted with Public Consulting Group, Inc. (PCG) to audit ?fteen (l5) mental health and substance abuse providers statewide. In 20l2, these providers constituted approximately 87% of all Core Service Agency (CSA) spending for Medicaid and non-Medicaid behavioral health services'. audit consisted of three main components: I) Clinical Case File Audit a review of case ?le documentation, including staf?ng quali?cations and credentials; 2) l?'Billing Systems Audit a review of the billing system itself, as well as the protocols and processes employed by the provider; and, 3) Enterprise Audit - a review of the organization and its key stakeholders, third party contracts, and other stakeholder relationships. Utilizing an approach developed and re?ned through auditing behavioral health providers nationally and tailored to New Mexico?s payment rules and regulations, multi-faceted audit arrived at the following ?ndings: 1) Clinical Findings: Identi?ed more than $36.0 million in overpayments to these IS providers over a three-year period from 2009-2012. This amounts to nearly l5% of all payments made to these providers. A 2003 Congressional General Accounting Of?ce (GAO) report stated that Medicaid fraud, waste, and abuse is expected to be 3% to 9% of all payments. PCG recommends the collection of these overpayments. 2) IT/Billing System Findings: No material ?ndings, though PCG did identify weaknesses in provider billing processes, including lack of audit trails when it comes to changes made in systems. Generally, PCG recommends that providers tighten billing process controls. 3) Enterprise Findings: Identi?ed potential conflicts of interests of some individuals and some of the audited providers. PCG recommends that the State of New Mexico further review instances of potential con?icts of interest. Core Service Agencies, or CSAs, are provider organizations that have been designated by the New Mexico Behavioral Health Collaborative to be responsible for clinical coordination of care for children and adults. audit included 12 of the state?s 15 CSAs. Estimated percentage of CSA spending utilized 2009-2012 total Spending for each CSA. Page I a A WW State of New Mexico Human Services Department PUBLIC Beliaworal Health Prowder Audits thour Executive Summary Summary of Clinical A mlit clinical case ?le 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 ?ndings. 2) Consumer case ?le review A review of a full year?s worth of case ?le documentation for selected consumers. These ?ndings are not extrapolated, but can be used to identify de?ciencies that cannot be identi?ed when viewing a single claim. PCGs clinical case ?le review revealed moderate to signi?cant levels of non-compliance with state payment rules and regulations. Generally, the providers reviewed in this audit lack many of the appropriate safeguards against overbilling and would bene?t from targeted technical assistance. Additionally, ?ndings reveal de?ciencies in accuracy of clinical documentation, which signi?es potential quality of care concerns that should be further reviewed by the State of New Mexico. PCG utilized an audit tool developed and re?ned through auditing behavioral health providers nationally and tailored to New Mexico?s payment rules and regulations. For the randomly sampled claims PCG utilized a statistically signi?cant extrapolation methodology to identify more than $33.8 million in overpayments to these l5 providers over a three-year period from 2009-2012. With the consumer case ?le, or ?longitudinal,? reviews PCG identi?ed an additional $2.1 million in overpayments to these 15 providers over the same three year period, for total estimated overpayments of $36.0 million (nearly 15% of claims paid during this period). Below are non-compliance rates and extrapolated overpayments by provider: Page II ?3 0 Ag ii i Human Services Department PUBLIC Behavioral Health Provider Audits 'G'Itour Executive Summary I State of New Mexico Provider A 27.3% 59.6% $161 3 Provider 40.0% 49.7% Provider 13.3% 27.8% $78,854 Provider 55.3% 38.2% $5 I Provider 21.8% 70.7% $1 Provider 3.3% $7 41.1% $14 18 Provider 29.3% 64.8% $179 Provider 17.3% $61 20.0% $43 137 Provider 1 6.0% $57 14 97.4% 736 Provider .1 18.0% 97.1% 1 Provider 36.7% $1 140 34.8% $1 Provider 35.3% 757 84.6% $21 Provider 15.3% $1 98.6% $437 $1 Provider 21.1% $9 71 1 60.2% $33 3 $9 Provider 0 14.9% 35.5% $291 36 Grand Total 23.7% $33 415 57.1% 1 $3 It is important to note that only the more egregious errors were used to extrapolate the amounts owed across the universe of claims for these providers. A more strict review of the randomly sampled provider claims originally indicated a non-compliance rate of 74%. PCG classi?ed a number of these ?ndings as ?poor documentation practices" that should be remedied through a combination of trainings, technical assistance, and clinical and management assistance. These errors included missing signatures, inadequate case note completion, and below standard preparation of plans of care. Had PCG used these errors in the extrapolation, the resulting overpayment amounts would have been much greater. PCG considers the extent of its ?ndings to be a signi?cant concern for the State of New Mexico. In a 2003 reportz, the Congressional General Accounting Of?ce (GAO) estimated that fraud, waste, and abuse amounted to between 3% and 9% of total Medicaid spending. Using this GAO study as a base, this audit reveals overpayments that are double what can be expected. 3 General Accounting Of?ce, ?Major Management Challenges and Program of Health and Human Services." 2003. Page 111 State of New Mexico I Human Services Department mum (-ONSUI Beltavnoral Health Prowder Audits Executive Summary Summary QfIT/Billing ystems Audit PCG did not identify any speci?c instances of tampering with the providers? billing systems. This ?nding must be quali?ed for several reasons. First, PCG was unable to complete a comprehensive review of all billing systems as one of the billing systems vendors. Anasazi. prohibited providers from sharing system manuals, as they were considered proprietary (noted in an email that PCG viewed from Anasazi to one of the audited providers). Additionally, PCG identi?ed areas of weaknesses in provider practices. including: 0 Lack of audit trail for the creation of and changes made to claim records in provider billing systems; 0 Lack of audit trail for any changes made to the 837 reports (billing system outputs) prior to ?nalizing in the Automated Clearing House portal. Summary of Enterprise Audit Lastly, enterprise audit sought to a) provide the state with a clearer view of how its provider system is organized and b) identify any potential appearances of con?icts of interest for the organization and its key board members and employees. The enterprise audit revealed that some providers may have potential con?icts of interest that should be further reviewed by the State of New Mexico. Examples of the types of potential con?icts of interest and areas that PCG recommends further research include: 0 Unusual compensation and/or bene?ts to some key stakeholders; 0 Key stakeholders? relationships with related parties with ?nancial interests in transactions; 0 Some arrangements with third parties are unclear as to the level of effort and compensation for some executives; and, - Non-disclosure of all third party contracts. Scorecard and Risk Tier Results Based on the clinical case ?le compliance outcomes and ?ndings related to controls, PCG developed, in conjunction with HSD, a ?scorecar for each provider. Below, PCG has Page lV A A AA A State of New Mexico I Human Services Department PUBLIC CONSULHNG Behavioral Health Provider Audits Executive Summary organized the providers? scorecard results in relation to each other. The scorecard ranges from ?Signi?cant Non-Compliance? to ?Compliant.? Provider-Scorecard PCG then used these provider scorecard ratings to categorize providers into ?Risk Tiers,? replete with recommended state actions, as follows: [met a [tidings Reemmnended State A Minus 1 Findings that include missing 0 Provide trainings and clinical documents, etc. assistance as needed. 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management to improve processes. 3 Signi?cant ?ndings, including - Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. 0 Potentially embed clinical management to improve processes. 0 Potential change in management. 4 Credible Allegation of Fraud 0 Mandatory change in management. Page A State of New Mexico Human Services Department I BehaVIoral Health Pr??VIder (.thUl' Executive Summary Based on scorecard methodology, each of the 15 providers was categorized into a Risk Tier, the results of which are shown below. Recommended State .4 ctimr Provider 0 Provide trainings and clinical assistance as needed. 2 0 Provide trainings and clinical assistance as M, C, l, L, H, andN needed. 0 Potentially embed clinical management to improve processes. 3 0 Provide trainings and clinical assistance as E, G, A, F, K,Oand needed. 0 Potentially embed clinical management to improve processes. Potential change in management. 4 0 Mandatory change in management. See NOT E. below N0 Please note that Tier 4: Credible Allegation of Fraud is a determination that can only be made by the State of New Mexico. PCG utilized results from its clinical case ?le audit and I T/billing system audit to develop the scorecard, which translated into providers being categorized in Tiers 1, 2, and 3. The State of New Mexico may determine that information provided in the case file, I T/billing system, and enterprise audits constitutes a re-categorization of one or more providers into a higher risk tier, including Tier 4. Background in February 2013, the New Mexico Human Services Department (HSD) determined the need for a comprehensive clinical and billing audit of select providers within its behavioral health system and engaged Public Consulting Group (FCC) to conduct these audits. Claims data mining by the state?s behavioral health vendor revealed a signi?cant number of potential billing abnormalities. These potential billing abnormalities included, but were not limited to, the following data and case ?le ??ndingsz? Page Vl A State of New Mexico Human Services Department PUBLIC CONSUI Behavroral Health ProVIder Audits GROUP Executive Summary - Cross billing at different locations for the same member potentially overlapping time; uncertainty as to who rendered the service (if rendered at all); - Insuf?cient documentation; - Cross billing multiple codes and double billing individual and group therapy); - Upcoding individual therapy (compared to the average time billed per code in the peer group] - Excessive billing for rehab; including requesting authorization for a consumer on medical leave; - Suspicious high volume days per one code; overbilling for inappropriate codes; rehabilitation billed for large units on a given date to one clinician; excessive hours per day billed by practitioner; excessive hours of service billed per patient per code; billing for services duplicative in nature; Identifying Provider as the rendering clinician; - No medical necessity reviews to determine basis for long-term - Forging clinician records to incorporate more time than truly performed; - Out of home placement services outside norm of service; doubtful medical need; Billing outpatient services the same day as bundled services. Not all of the aforementioned potential billing issues can be addressed with a single audit, particularly when an objective of the audit is to identify recoupable overpayments. In order to recoup across a universe of paid claims, a more comprehensive review is required. Narrowly focusing on one particular suspicious trend in a provider?s claims history inhibits the ability of the auditor and the state to extrapolate those results across the entire claims history. Rather than attempting to address each provider?s uniquely identi?ed issues, PCG worked with HSD to develop a comprehensive approach that would scrutinize individual providers holistically (as opposed to looking at a few aberrant trends that may or may not run afoul of policy even if substantiated) and the system at large. This approach was characterized by three main goals: 1) Identify potential credible allegations of fraudulent activity. 2) Identify regulatory compliance levels of behavioral health providers. 3) Identify areas of weakness that must be strengthened prior to the implementation of Centennial Care. PCG was tasked with conducting onsite audits of selected providers to examine case ?les supporting speci?c claims, IT systems and processes, and adherence with compliance protocols, and to examine existing relationships, ?nancial or other, among providers and other entities. The onsite audits were conducted in February and March and included interviews with relevant Page VII a r?s State of New Mexico Human Services Department mmuc ONSULHNC. BchaVIoral Health ProVIder Audits Executive Summary provider staff, collection of hard copy and electronic ?le documents related to the above mentioned areas, and examination and manual testing of IT systems. The onsite visits were supplemented by desk reviews of collected documentation at a location separate from the provider site. approach is described in more detail in the body of the full report. Key Findings While each provider is unique with respect to clinical ?ndings, PCG identi?ed certain common themes across many of the IS providers reviewed, which are described below. For each provider, a section is included in the appendix that shows the detailed clinical ?ndings speci?c to that provider. ?ndings include: 0 More than $37.3 million in overpayments for these IS providers over a three and a half year period (July 2009-January 2013). This extrapolated overpayment amounts to of total payments from state sources to these providers during this time period. - Non-compliance with many New Mexico state rules and regulations. Pervasive issues that PCG identi?ed across providers include: Randomly Samgled Claims 0 Community Support Workers lacked evidence of completion of the required training per the service de?nition. 0 Assessments evaluations) were not up to date (within last 12 months) to determine if the consumer continued to meet the need of the rendered service. I Incomplete critical information such as Five Axis diagnosis. Substance abuse history was absent for most consumers with a dual- diagnosis of mental health and substance abuse. 0 Treatment plans were not up-to-date and individualized per consumer. Updated treatment plans are necessary to determine any changes to goals/objectives in addition to progress or lack of progress by the consumer. Without continuously updated treatment plans, it is impossible to determine if the treatment interventions still meet the behavioral health needs of the consumer. I Goals/Objectives were not measurable and did not document achievable target dates based on the consumer?s needs. I Service speci?c clinical interventions used to reach goals/objectives were absent. Page 0 WIN PUBLIC CONSULTING Slate of New Mexico Human Services Department Behavioral Health Provider Audits Executive Summary I Discharge plans and estimated length of treatment were not documented for all consumers. Documented discharge plans were rarely individualized. 0 Consumer Documentation I Consents for medications rendered were absent. I Documentation frequently did not describe the clinical interventions, progress or lack of progress toward goals, and next steps in treatment. I Interventions in the progress notes did not always link to the consumer?s treatment plan or support the program de?nition of the billed service. I Progress notes did not contain a start and stop time or a duration that would enable a determination as to whether the billed time was accurate. I Billed units did not match the units documented on the progress notes. I Intensive Outpatient Program progress notes did not contain the treatment modalities used as required in the service de?nition. I Documented evidence of the required treatment team was absent for most team services. C) Longitudinal File Review Findings 0 Safety/Risk Assessments were not completed or updated for consumers who were assessed to have current or past suicidal ideations homicidal ideations self harm or domestic violence issues. 0 Treatment plans were not up-to-date and individualized per consumer. I Plans contained the same goals/objectives for more than 12 months. I Potential overutilization of services without documented justi?cation of? the service related to extensive length of stay. 0 Consumer Documentation I Documentation frequently did not describe the clinical interventions, progress or lack of progress toward goals, and next steps in treatment. I Progress notes did not contain a start and stop time or a duration that would enable a determination as to whether the billed time was accurate. I Billed units did not match the units documented on the progress notes. - Weaknesses identi?ed in providers? billing processes. PCG identi?ed weaknesses in internal claims processes. PCG was unable to complete a comprehensive review of all billing systems as one particular billing software vendor was unwilling to allow providers to share with PCG important documentation and information about the system. Page 1X 2% A ONSLIH mtour State of New Mexico Human Services Department Behavioral Health Provider Audits Executive Summary Potential con?icts of interest in selected providers. PCG identi?ed areas of potential con?icts of interest among some providers, individuals, and related parties. Examples of the types of potential con?icts of interest and areas that PCG recommends further research include: 0 Unusual compensation and/or bene?ts to some key stakeholders; 0 Key stakeholders? relationships with related parties with ?nancial interests in transactions; 0 Some arrangements with third parties are unclear as to the level of effort and compensation for some executives; and, Non-disclosure of all third party contracts. Key Recommendations Standardize clinical documentation across providers. In order to ensure that all critical behavioral health consumer information is gathered and properly documented, PCG recommends that standardized forms be used across all providers. The standardized forms at a minimum would include assessments, treatment plans, and progress notes (daily/weekly/logs). Please refer to Section 4 of the report for speci?c recommendations. Implement a comprehensive program integrity effort for behavioral health services. PCG recommends this Pl effort be written into MCO contracts and be implemented by the state for non-Medicaid programs. This means more than just post-payment auditing. Traditional ?pay and chase? models should be supplemented by prc-payment measures and more proactive provider education, oversight and monitoring efforts to proactively prevent errors from occurring prior to payment. Provide technical assistance to providers in the areas of clinical best practices and billing processes and procedures. Review and revamp New Mexico?s behavioral health provider billing rules and regulations. Speci?cally, PCG recommends certain "best practices? that should be required information. Please refer to Section 4 of the report for recommendations. Enforce payment regulations. Payment rules and regulations are developed for several reasons, the primary of which is to ensure that consumers receive high-quality care. Page 4% State of New Mexico Human Services Department PUBLIC CONSUH WE. Behavnoral Health Prowder Audits (?our Executive Summary 2% Hill Maximize the utility of the editing capabilities of claims processing systems to prevent overpayments. Where functionality is lacking or inadequate to sufficiently vet claims pre-submission to avoid inappropriate billing. providers should engage in discussions with their EMR vendors to identify and implement the requisite safeguards. Thorough training of billing staff on new or previously unused system functionality will further ensure proper front end billing. - Complete additional reviews of potential con?icts of interest. Beyond the recommendations mentioned above, PCG was asked to provide additional recommendations for the New Mexico behavioral health system, based on the firm?s national experience working with behavioral health and other community based providers. PCG recommends the following: - Convene stakeholder (state, vendors, and providers) workgroups to develop Outcomes Measures. Working together, stakeholders can de?ne the particular outcomes that New Mexico chooses to pursue. With specific measures in hand, work can begin on collecting the relevant information and data points, which will spawn fruitful conversations about quality of care and reimbursement reform. Enforce Behavioral Health Providers? important role in Health Care Reform. A primary argument in favor of health care reform is its potential to achieve cost savings by focusing attention on the small percentage of the population that consumes the largest share of health care services. Better management of care for those individuals can concurrently yield improvements in quality and decreased costs for services. Particularly in the case of publicly funded programs, individuals with chronic illnesses o?en have a primary or secondary behavioral health diagnosis. Behavioral health providers must be front and center in conversations regarding proactive management of care for this population. Page XI Junc2l,20l3 TABLE OF CONTENTS 1. Introduction 2. Background and Understanding 2.1 Purpose of Procurement 2.2 Scope of Work 3. Audit Approach 3.1 Preparing and Deploying Audit Teams 3.2 Establishing protocols for each component of the audit 3.3 Onsite data collection 3.4 Coordination with State and Managed Care Organization Staff 3.5 Production of Final Audit Report 4. Case File Reviews 4.1 Case File Review Methodology 4.2 Provider Selection 4.3 Claim Selection 4.3.1 Random Samples of DOS 4.3.2 Longitudinal Reviews 4.4 Audit Tool Reviews 4.5 Extrapolation Methodology 4.6 Key Case File Findings 4.7 Key Recommendations 5. IT/Billing Systems Reviews Appendices Audit Protocols Provider Audit Counseling Associates, Inc., Audit Public Consulting Group, Inc. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Page i Sections 1 - 5 1. Introduction 2. Background and Understanding 2.1 Purpose of Procurement 2.2 Scope of Work 3. Audit Approach 3.1 Preparing and Deploying Audit Teams 3.2 Establishing protocols for each component of the audit 3.3 Onsite data collection 3.4 Coordination with State and Managed Care Organization Staff 3.5 Production of Final Audit Report 4. Case File Reviews 4.1 Case Fife Review Methodology . 4.2 Provider Selection 4.3 Claim Selection 4.3.1 Random Samples of DOS 4.3.2 Longitudinal Reviews 4.4 Audit Tool Reviews 4.5 Extrapolation Methodology 4.6 Key Case File Findings 4.7 Key Recommendations 5. IT/Billing Systems Reviews ll ll . PUBLIC CONSULTING GROUP 1. Introduction 4% State of New Mexico A 4% fr-s" rs? I Human Services Department I) Behavioral Health Provider Audits PUBLIC CONSULT INC. Final Report GROUP 1. Introduction In February 2013, the New Mexico Human Services Department (HSD) contracted with Public Consulting Group, Inc. (PCG) to audit ?fteen (l5) mental health and substance abuse providers statewide. in 20l2, these providers constituted approximately 87% of all Core Service Agency (CSA) spending for Medicaid and non?Medicaid behavioral health services?. audit consisted of three main components: I) Clinical Case File Audit a review of case ?le documentation, including staf?ng quali?cations and credentials; 2) IT/Billing Systems Audit a review of the billing system itself, as well as the protocols and processes employed by the provider; and, 3) Enterprise Audit a review of the organization and its key stakeholders, third party contracts, and other stakeholder relationships. Utilizing an approach developed and re?ned through auditing behavioral health providers nationally and tailored to New Mexico?s payment rules and regulations, multi-faceted audit arrived at the following ?ndings: 1) Clinical Findings: Identi?ed more than $36.0 million in overpayments to these 15 providers over a three-year period from 2009-2012. This amounts to nearly 15% of all payments made to these providers. A 2003 Congressional General Accounting Of?ce (GAO) report stated that Medicaid fraud, waste, and abuse is expected to be 3% to 9% of all payments. PCG recommends the collection of these overpayments. 2) IT/Billing System Findings: No material ?ndings, though PCG did identify weaknesses in provider billing processes, including lack of audit trails when it comes to changes made in systems. Generally, PCG recommends that providers tighten billing process controls. 3) Enterprise Findings: Identi?ed potential conflicts of interests of some individuals and some of the audited providers. PCG recommends that the State of New Mexico further review instances of potential conflicts of interest. Core Service Agencies, or CSAs, are provider organizations that have been designated by the New Mexico Behavioral Health Collaborative to be responsible for clinical coordination of care for children and adults. audit included 12 of the state's 15 CSAs. Estimated percentage of CSA spending utilized 2009-2012 total spending for each CSA. CONFIDENTIAL Page 1 4% A State of New Mexico I Human Services Department i Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Summary of Clinical Audit clinical case ?le review utilized two different methodologies for each provider: 1) Random sampling of provider claims Audit of randomly sampled claims that were submitted by the providers. The sampling methodology allows for a statistically valid extrapolation of the ?ndings. 2) Consumer case ?le review A review of a full year?s worth of case ?le notes for selected consumers. These ?ndings are not extrapolated, but can be used to identify de?ciencies that cannot be identi?ed when viewing a single claim. PCGs clinical case ?le review revealed moderate to signi?cant levels of non-compliance with state payment rules and regulations. Generally, the providers reviewed in this audit lack many of the appropriate safeguards against overbilling and would bene?t from targeted technical assistance. Additionally, ?ndings reveal de?ciencies in accuracy of clinical documentation, which signi?es potential quality of care concerns that should be further reviewed by the State of New Mexico. PCG utilized an audit tool developed and re?ned through auditing behavioral health providers nationally and tailored to New Mexico's payment rules and regulations. For the randomly sampled claims PCG utilized a statistically signi?cant extrapolation methodology to identify more than $33.8 million in overpayments to these 15 providers over a three-year period from 2009-2012. With the consumer case ?le, or ?longitudinal,? reviews PCG identi?ed an additional $2.1 million in overpayments to these 15 providers over the same three year period, for total estimated overpayments of $36.0 million (nearly 15% of claims paid during this period). Below are non?compliance rates and extrapolated overpayments by provider: CONFIDENTIAL Page 2 4% a far-a State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Provider A 27.3% 59.6% Provider 40.0% 49.7% Provider 13.3% 27.8% Provider 55.3% 38.2% Provider 21.8% 70.7% Provider 3.3% 41.1% Provider 29.3% 64.8% Provider 17.3% 20.0% Provider 1 6.0% 97.4% Provider .1 18.0% 97.1% Provider 36.7% $1 140 34.8% $1 Provider 35.3% 84.6% 321 Provider 15.3% $1 98.6% $437 $1 Provider 21.1% $9 60.2% 3 $9 Provider 0 14.9% 35.5% $291 436 745 Total 23.7% 333 15 57.1% 1 4 $35,980 9 It is important to note that only the more egregious errors were used to extrapolate the amounts owed across the universe of claims for these providers. A more strict review of the randomly sampled provider claims originally indicated a non-compliance rate of 74%. PCG classi?ed a number of these ?ndings as ?poor documentation practices? that should be remedied through a combination of trainings, technical assistance, and clinical and management assistance. These errors included missing signatures, inadequate case note completion, and below standard preparation of plans of care. Had PCG used these errors in the extrapolation, the resulting overpayment amounts would have been much greater. PCG considers the extent of its ?ndings to be a signi?cant concern for the State of New Mexico. in a 2003 reportz, the Congressional General Accounting Of?ce (GAO) estimated that fraud, waste, and abuse amounted to between 3% and 9% of total Medicaid spending. Using this GAO study as a base, this audit reveals overpayments that are double what can be expected. Summary of I T/Billing Systems A udr't PCG did not identify any speci?c instances of tampering with the providers? billing systems. This ?nding must be quali?ed for several reasons. First, PCG was unable to complete a 2 General Accounting Of?ce, ?Major Management Challenges and Program of Health and Human Services.? 2003. CONFIDENTIAL Page 3 Ag State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report GROUP comprehensive review of all billing systems as one of the billing systems vendors, Anasazi, prohibited providers from sharing system manuals, as they were considered proprietary (noted in an email that PCG viewed from Anasazi to one of the audited providers). Additionally, PCG identi?ed areas of weaknesses in provider practices, including: 0 Lack of audit trail for the creation of and changes made to claim records in provider billing systems; - Lack of audit trail for any changes made to the 837 reports (billing system outputs) prior to ?nalizing in the Automated Clearing House portal. Summary of Enterprise A udit Lastly, enterprise audit sought to a) provide the state with a clearer view of how its provider system is organized and b) identify any potential appearances of conflicts of interest for the organization and its key board members and employees. The enterprise audit revealed that some providers may have potential conflicts of interest that should be further reviewed by the State of New Mexico. Examples of the types of potential con?icts of interest and areas that PCG recommends further research include: 0 Unusual compensation and/or bene?ts to some key stakeholders; 0 Key stakeholders? relationships with related parties with ?nancial interests in transactions; 0 Some arrangements with third parties are unclear as to the level of effort and compensation for some executives; and, Non-disclosure of all third party contracts. Scorecard and Risk Tier Results Based on the clinical case ?le compliance outcomes and ?ndings related to IT controls, PCG developed, in conjunction with a ?scorecar for each provider. Below, PCG has organized the providers? scorecard results in relation to each other. The scorecard ranges from ?Signi?cant Non-Compliance? to ?Compliant.? CONFIDENTIAL Page 4 gag?s A A State'of New Mexico I I Human SerVIces Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP .MWScomcard Compliance Gwyn?! PCG then used these provider scorecard ratings to categorize providers into ?Risk Tiers,? replete with recommended state actions, as follows: Types of inding 3mm :1 minus 1 Findings that include missing 0 Provide trainings and clinical documents, etc. assistance as needed. 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management to improve processes. 3 Signi?cant ?ndings, including 0 Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. - Potentially embed clinical management to improve processes. I Potential change in management. 4 Credible Allegation of Fraud 0 Mandatory change in management. CONFIDENTIAL Page 5 4% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Based on scorecard methodology, each of the IS providers was categorized into a Risk Tier, the results of which are shown below. Rer'mmnumlerl State ctiou Provider Provide trainings and clinical assistance as needed. 2 0 Provide trainings and clinical assistance as needed. - Potentially embed clinical management to improve processes. 3 0 Provide trainings and clinical assistance as E, G, A, F, andB needed. 0 Potentially embed clinical management to improve processes. Potential change in management. 4 - Mandatory change in management. See NOTE, below Please note that Tier 4: Credible Allegation of Fraud is a determination that can only be made by the State of New Mexico. PCG utilized results from its clinical case ?le audit and IT/billing system audit to develop the scorecard, which translated into providers being categorized in Tiers 1, 2, and 3. The State of New Mexico may determine that information provided in the case ?le, I T/billing system, and enterprise audits constitutes a re-categorization of one or more providers into a higher risk tier, including Tier 4. CONFIDENTIAL Page 6 2. Background and Understanding 2.1 Purpose of Procurement 2.2 Scope of Work State of New Mexico I Human Services Department i I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 2. BACKGROUND AND UNDERSTANDING 2.1 Purpose of Procurement In February 2013, the New Mexico Human Services Department (HSD) determined the need for a comprehensive clinical and billing audit of select providers within its behavioral health system and engaged Public Consulting Group (FCC) to conduct these audits. Claims data mining by the state?s behavioral health vendor revealed a signi?cant number of potential billing abnormalities. These potential billing abnormalities included, but were not limited to, the following ??ndings?: - Cross billing at different locations for the same member potentially overlapping time; uncertainty as to who rendered the service (if rendered at all); - Insuf?cient documentation; - Cross billing multiple codes and double billing individual and group therapy); - Upcoding individual therapy (compared to the average time billed per code in the peer group); - Excessive billing for rehab; including requesting authorization for a consumer on medical leave; - SusPicious high volume days per one code; overbilling for inappropriate codes; rehabilitation billed for large units on a given date to one clinician; excessive hours per day billed by practitioner; excessive hours of service billed per patient per code; billing for services duplicative in nature; - Identifying Provider as the rendering clinician; - No medical necessity reviews to determine basis for long-term - Forging clinician records to incorporate more time than truly performed; - Out of home placement services outside norm of service; doubtful medical need; - Billing outpatient services the same day as bundled services. Not all of the aforementioned potential billing issues can be addressed with a single audit, particularly when an objective of the audit is to identify recoupable overpayments. In order to recoup across a universe of paid claims, a more comprehensive review is required. Narrowly focusing on one particular suspicious trend in a provider?s claims history inhibits the ability of the auditor and the state to extrapolate those results across the entire claims history. Rather than attempting to address each provider?s uniquely identi?ed issues, PCG worked with HSD to develop a comprehensive approach that would scrutinize individual providers holistically (as opposed to looking at a few aberrant trends that may or may not run afoul of policy, even if substantiated) and the system at large. This approach was characterized by three main goals: CONFIDENTIAL Page 7 as A State of New Mexico Human Services Department I Behavioral Health Provider Audits PUBLIC. gloomsuu Final Report 1) Identify potential credible allegations of fraudulent activity; 2) Identify regulatory compliance levels of behavioral health providers; and, 3) Identify areas of weakness that must be strengthened prior to the implementation of Centennial Care. PCG was tasked with conducting onsite audits of selected providers to examine case ?les supporting speci?c claims, IT systems and processes, and adherence with compliance protocols, and to examine existing relationships among providers (enterprise audit). The results of the enterprise portion of the audits will be presented in a separate report. The onsite audits were conducted in February and March, and included interviews with relevant provider staff, collection of hard copy and electronic ?le documents related to the above mentioned areas, and examination and manual testing of IT systems. The onsite visits were supplemented by desk reviews of collected documentation at a location separate from the provider site. approach is described in more detail in the next section. 2.2 Scope of Work Under the signed Agreement between H80 and PCG, PCG was engaged to serve as project manager in coordinating audits and analysis of 15 of New Mexico?s Medicaid managed care organization (MCO) network of behavioral health providers. The providers were identified by the HSD. scepe of work included three main audit components for each of the 15 providers: 1) Clinical Case File Audits to ensure that providers are adhering to New Mexico payment rules and regulations; 2) IT/Billing Systems Audit to ensure that systems are being used properly and in accordance with New Mexico payment rules and regulations; and 3) Enterprise Audit to ensure that each of the organizations? contractual and business relationships are conducted in accordance with Federal and New Mexico law, rules, and regulations. PCG's approach and protocols for each of these audit components are described in the subsequent sections of this report. CONFIDENTIAL Page 3 3. Audit Approach 3.1 Preparing and Deploying Audit Teams 3.2 Establishing protocols for each component of the audit 3.3 Onsite data collection 3.4 Coordination with State and Managed Care Organization Staff 3.5 Production of Final Audit Report as A A State of New Mexico Human Services Department II I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 3. AUDIT APPROACH 3.1 Preparing and Deploying Audit Teams Under the Agreement between HSD and PCG, PCG was responsible for the organization of onsite visits and offsite reviews, including preparing audit teams. Each project team was comprised ofthree t0'five individuals including the following Specific roles: - Team Lead: The Team Lead was responsible for overseeing the general operation of the onsite visits. Speci?c functions included: 0 Initiating onsite communication with provider staff; 0 Facilitating the entrance discussion, including explaining the purpose of the visit, expectations for provider assistance and actions to be carried out/protocols to be followed by the audit team during onsite time; Coordinating team activities to ensure that team members were connected with the appropriate provider staff members and were able to collect the required information; 0 Conducting interviews with key provider administrative staff; and Facilitating the exit discussion and information/next steps to provider. communicating any additional 0 Administrative Support: Administrative support staff, which in some cases included team members with clinical experience, had primary responsibility for data collection and storage and provided as needed support to the other team members. Speci?c functions included: 0 Physically collecting documentation given by the provider, which in some cases included manually extracting documentation from case ?les; 0 Scanning and/or uploading all collected ?les; 0 Participating in as needed interviews with provider staff and documenting these interviews; 0 Identifying missing information and working with providers to obtain that information. CONFIDENTIAL Page 9 2% A. A State of New Mexico I Human Services Department ll Behavioral Health Provider Audits PUBLIC (.ONSULFINL Final Report GROUP 0 Information Technology Lead: The IT Lead had primary responsibility for working with the provider?s IT staff to analyze IT systems, their applications and functionality. Speci?c functions included: 0 Collecting documentation regarding IT infrastructure and all software systems currently in use, speci?cally those used for submitting claims to Optum and capturing other relevant clinical information; and 0 As appropriate, manually testing system functionality to determine the link between system inputs and outputs and to identify any areas of concern. In addition to the above mentioned PCG staff roles, for two weeks of the audit PCG team members were accompanied by State staff acting in administrative support roles. Inclusion of State staff in audit teams reinforced role as the authorizing entity for the audits and further ensured coordination of onsite audits between HSD and PCG. 3.2 Establishing protocols for each component of the audit PCG established auditing standards according to stated needs, with each component of the audit being assigned its own set of procedures, documentation requests and information collection tools. The speci?c components of the clinical and lT/billing audits and associated protocols are addressed in great detail in sections 4 and 5 of this report. 3.3 Onsite data collection Upon arriving at each provider site, PCG conducted an entrance conference at which the purpose of the audit was explained and provider staff were given the list of claims patient name, service rendered, date(s) of service, etc.) selected for auditing and asked to pull the appropriate medical records for the claims in question. PCG also provided a Document Request List that identi?ed all of the documentation (case ?le, lT/billing and enterprise) expected to be provided as part of the audit. The PCG team brought portable scanners to each provider location and any documents provided in hard (paper) copy were scanned and saved on a secure, laptop. Electronic ?les that were provided via USB drive or e-mail were also saved on the laptops. At the end of each day of the onsite audits, all ?les on the laptops were uploaded to a secure, HIPAA-compliant site for safe storage; ?les were then deleted from the laptops and all USB drives. 3.4 Coordination with State and Managed Care Organization Staff CONFIDENTIAL Page 10 a ease 2% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INL. Final Report GROUP Throughout the audit process, PCG worked closely with staff from both HSD and Optum, the managed care organization responsible for the administration of all State behavioral health funds, to keep both parties apprised of audit progress and to preemptively identify and discuss concerns related to consumer safety that might arise in relation to the audits. 3.5 Production of Final Audit Report Upon completion oFthe data collection, review and analysis processes, PCG was tasked with the development and submission to HSD of a ?nal audit report capturing all components of the audit process and highlighting key ?ndings and recommendations generated by the audits, both at the comprehensive system wide and provider-speci?c levels. This document serves as that report. For more details quCG' ?3 audit protocols. please see the Audit Protocols potion of this report. CONFIDENTIAL Page I 4. Case File Reviews 4.1 Case File Review Methodology 4.2 Provider Selection 4.3 Claim Selection 4.3.1 Random Samples of DOS 4.3.2 Longitudinal Reviews 4.4 Audit Tool Reviews 4.5 Extrapolation Methodology 4.6 Key Case File Findings Key Recommendations A A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 4. CASE FILE REVIEWS Clinical and case ?le reviews comprised the most signi?cant element of review. Administrative and clinical staff applied rigorous analysis to all paid claims selected for review. Our methodology focused on providing assurance that payment of claims is consistent with the administrative, credentialing, and clinical requirements set forth in the state?s payment regulations. 4.1 Case File Review Methodology At the start of the onsite audits, PCG presented providers with a noti?cation from HSD identifying the clients whose case ?les had been randomly selected for audit and requesting that the provider have available all related service documents for review,l not limited to: - assessments 0 evaluations 0 Treatment plans/person-centered plans 0 Service notes/progress notes 0 Consents - Referrals, and - Authorizations/service orders During onsite visits, the PCG team lead requested that the provider walk through the layout of the clinical record with the team to identify provider speci?c documents such as assessments, notes, consents, etc., the purpose of which was to aid ability to quickly and accurately identify the appropriate documentation within the case ?les. In addition to documentation regarding the services provided, PCG requested from the provider personnel documents related to the quali?cations for staff that rendered services to selected recipients. This documentation included at a minimum the relevant provider?s: 0 License to Practice 0 Academic/Professional Degrees (Master?s, Bachelor?s, High School, GED) 0 Resumes 0 Certi?cations (Board Certi?cation, Certi?ed Peer Specialist) 0 Trainings - Supervision Notes, if required by service 0 Criminal Background Checks (speci?c to Respite Care, Residential, Foster Care) CONFIDENTIAL Page 12 A A State of New Mexico II I I Human Services Department Behavioral Health Provider Audits PUBLIC Eo??uu' INC. Final Report In addition to staff-speci?c information, PCG requested agency documentation related to personnel policies and procedures for maintaining staff quali?cations. The goal of this credentialing review was to address questions including: 0 Does the rendering practitioner have a current valid license to practice? 0 Did he or she receive the appropriate training to provide the service rendered? - What is the status of clinical privileges at the institution designated by the service provider as the primary admitting facility, if applicable? 0 Does a valid drug enforcement agency (DEA) or controlled substance registration (CSR) certi?cate exist, if applicable? As with all gathered documentation, all ?les were scanned, logged, and uploaded to the secure website. Once the onsite data collection process had concluded and case ?les had been examined for completeness and accuracy, the reviewing clinicians were noti?ed that case ?les were ready for clinical review and the documents were downloaded from the secure website. All cases were reviewed using an audit tool containing a broad set of questions speci?cally geared toward identifying appropriate billing, excessive billing, overutilization, duplicate billing, and upcoding, and examining coordination of care and renderer of service. For certain service types, additional service-speci?c questions were applied in order to ensure a comprehensive program review that captured the unique facets of that particular service. 4.2 Provider Selection As stated previously, HSD identi?ed ?fteen (15) behavioral health providers in New Mexico for PCG to audit. The table below lists the providers that were audited as part of this process. I ,08 1,469 9,5 84,483 23,669,210 Border Area Mental Services Inc 117,492 Counseling Associates Inc 1 17,761 Families and Youth Inc 71,222 Hogares Inc 27 ,467 Partners in Wellness LLC 24,264 Pathways Inc 131,785 Presbyterian Medical Services 413,154 Easter Seals El Mirador 103,733 30,599,545 2,089,889 7,480,070 35,786,267 13,978,874 CONFIDENTIAL Page 13 4% A State of New Mexico 0 I I I:Iuman Services pepanment Behaworal Health Provrder Audits PUBLIC CONSULTING Final Report GROUP Service Organization for Youth Inc 897,468 Southern New Mexico Human Development 52,729 5 4,373,845 Southwest Counseling Center Inc I5 I ,769 14,934,445 Team Builders Counseling Services Inc 77,493,302 The Counseling Center Inc 78,965 6,344,l52 Valencia Counseling Services Inc 3 9,495,054 Youth Development Inc 26,343 2,870,455 Totals 2,395,46 7 3 250,678,527 The majority of the selected providers have several facilities located within the state, representing approximately I08 facilities, shown on the map below by county and organization. Helm-hr Hedlh learn of IN re?ne: audlud. 111qu than on the map by tauntyand emulation. Eldalgo CONFIDENTIAL Page 14 Ag A Hill I PU . GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 4.3 Claim Selection Due to the large volume of claims to analyze, audit sampling was applied. Audit sampling is the application of an audit procedure to less than 100% of the population to evaluate audit evidence within a class of transactions (claims) for the purpose of forming a conclusion concerning the population. The sample size creates a risk that the conclusions may be different from the conclusions that would have been reached based on the?wholepopulation. The most common types of sampling used are systematic sampling and random sampling. Random sampling ensures equal chances of selection, whereas systematic sampling involves using a ?xed interval between selections every 10th sample; ?rst interval has a random start). PCG applied random sampling to analyze the data. Sampling documentation includes the source of the population, the sampling method used, sampling parameters, items selected, details of audit tests performed, and conclusions reached. PCG executed a two-pronged approach to the selection of claims for review random samples for date of services and longitudinal reviews, both of which are described below. 4.3.1 Random Samples for Date of Service The ?rst prong was a full, statistically valid random sample of all claims for each provider. PCG randomly selected [50 claims from each provider for a full case ?le review. It was critical in selecting samples for case ?le review to ensure randomness so that the review was fair to the provider and was demonstrable as such to impartial parties during the due process phase, as many such reviews might be subject to appeal. During visit to Optum Health (Optum), Optum staff provided PCG with all paid claims data for providers subject to this review. PCG extracted the claims data and uploaded it into a SQL database for analytical review, validation, and ultimately sample selection. PCG employed RAT-STATS, an Of?ce of Inspector General (010) approved statistical sampling package to drive the sample selection for this engagement. PCG has employed RAT-STATS in multiple engagements and is well-versed in all facets of the program. The program produces a ?seed? number to demonstrate the randomness of the sample should a provider appeal on the grounds that claims were selectively targeted and do not represent the entirety of their claim universe. The statistically valid random sample enables PCG to extrapolate any findings over the entire universe of claims for a provider in determining overpayment amounts. CONFIDENTIAL Page 15 A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 4.3.2. Longitudinal Reviews The second prong of our approach was to conduct a targeted claim selection process. Through its data analytics process and through tips from whistleblowers, Optum had identified potentially outlying claims for each of the providers under audit. Several of the procedure codes identi?ed as potentially being overbilled are codes billed in IS minute increments and are billed over an extended period of time. it is often concerning to payers of health care claims when the units of service do not decrease over time within these codes for a given individual and is sometimes a ?red flag? that a provider is billing for that service for that individual in an ?auto-pilot? mode or that the consumer is not making the desired progress. For these types of trends, it is not possible to diagnose a billing issue by reviewing only a single date of service. In some cases, one may conclude that these trends represent potentially abusive billing and in others that the duration and intensity of services are appropriate for that consumer. One cannot, however, conclude these things by looking at a single point in time. Through a targeted claim selection process, PCG identi?ed highly utilized codes (as determined by their percentage of total paid claims to the provider) by individual providers. Following the selection of the codes, PCG isolated the consumers for whom the greatest number of units for these procedure codes had been billed over a 12-month period (Calendar Year 2012), removed those claims from the universe of claims subject to random sampling, requested documentation associated with claims submitted on behalf of those consumers and audited the entire length of stay. This allowed our review team to ensure through examination of treatment plans, service authorizations, progress notes, and other documentation that the services were, in fact, taking place and that the high level of service was necessary for that consumer given the diagnosis and goals of the individual. For each provider, PCG identi?ed the 2-3 such procedure codes with the highest spend and selected the 5 consumers with the most units billed. It should be noted that the targeted claim selection process is not statistically valid and cannot be extrapolated to claims other than those claims that are reviewed. It is intended to provide an extensive, thorough review for a small number of consumers so that HSD can determine if a more widespread review is warranted. 4.4 Audit Tool Reviews The audit tool questions were developed based on both the New Mexico Administrative Code and the New Mexico lnteragency Behavioral Health Service Requirements and Utilization Guidelines. A broad set of questions was employed, coupled with more speci?c questions tailored for each service sampled. CONFIDENTIAL Page 16 a: A State of New Mexico I I I Human Services Department i Behavioral Health Provider Audits PUBLIC Final Report The broad set of questions in the tool speci?cally related to excessive billing, overutilization, duplicate billing, coordination of care, upcoding, and renderer of service. Some of the key questions asked about each claim included: I. Do the units paid match the units of service documented for the sampled procedure code? Was the amount of rendered units appropriate for the recipient? (excessive billing 2. Was the service delivered medically necessary and appropriate (overutilization)? 3. Does the documentation support, or relate to, the rendered service? 4. Does the procedure code match the documented duration of time spent serving the member for the encounter billed (upcoding)? 5. Were multiple units/encounters billed for the same procedure code for the same recipient in the same day? 6. Were the billed services rendered by quali?ed staff? In addition to auditing for excessive billing, overutilization, duplicate billing, coordination of care, upcoding, and inappropriate service delivery as outlined above, a speci?c set of audit questions developed and utilized for each sampled service type covered the categories below: 0 Service De?nition 0 Target Population 0 Program Requirements 0 Provider Requirements 0 Staff Requirements 0 Documentation Requirements 0 Service Exclusions - Admission/Continuing/Discharge Criteria For each claim, the reviewing clinician provided a response to each clinical question. Possible responses were: - No/Not Met 0 Not Applicable - Yes/Yes Met Comments are required for No/Not Met and followed by the New Mexico Administrative Code (NMAC), New Mexico Service De?nitions, and Level of Care citation verbiage. CONFIDENTIAL Page 17 \cs? A A A A State of New Mexico I I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 4.5 Extrapolation Methodology PCG performed both a targeted review and a statistically valid random sample review of all billed behavioral health services procedure codes on behalf of HSD. First, PCG targeted one year?s worth of billed high risk procedure codes from the ?ve highest claimed-for recipients at each of the providers and performed an administrative and clinical review of the validity of each billed claim. The resulting overpayment validated by ECG was calculated based on the dollar value of only those paid claims from the universe of claims reviewed found to be out of compliance with New Mexico?s clinical and/or billing criteria. The results of these reviews was not extrapolated beyond the speci?c claims PCG reviewed. Second, PCG selected a statistically valid random sample of ISO of the remaining claims from the universe of claims paid to each provider paid between July 1, 2009 and January 31, 2013. The resulting overpayment validated by PCG was representative of the universe of claims from which the sample was selected and was extrapolated over the entire universe of claims (excluding those claims selected for targeted review) in compliance with auditing procedure regulations found in New Mexico Administrative Code Title 8, Chapter 35 Part 2. Targeted Review The ?rst goal of the review process was to identify a targeted selection of claims based on the procedure codes billed. Those codes include: 9079] Diagnostic Evaluation 90801 Diagnostic Evaluation 90802 Interactive Evaluation 90804 Outpatient-?-20-30 minutes 90806 0utpatient?45-50 minutes 90807 Outpatient with 45-50 minutes 90808 Outpatient?75-80 minutes 90812 Interactive minutes 90814 Interactive Therapy?75-80 minutes 90834 Outpatient ?45 minutes 90837 Outpatient?~60 minutes 90846 Family Therapy 90847 Family Therapy 90849 Outpatient Services CONFIDENTIAL Page 18 A State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report at 1 CONSULTING caour 90853 Group Therapy 90862 Medication Management 992 I 2 Of?ce/Outpatient Visit 99214 Of?ce/Outpatient Visit H0002 Behavioral Health Screening H0015 Intensive Outpatient Program H0019 Transitional Living Services H0031 Mental Health Assessment H0039 Assertive Community Treatment H0041 Foster Care(Shelter) H0048 Alcohol/Drug Testing H2010 RN Medication Monitoring H201 1 Crisis intervention Services H2014 Behavior Management Services H2015 H0, HN, H2017 Rehabilitation H2023 Supported Employment Services H2033 Multi-Systematic Therapy Q3014 Telehealth Facility Fee/Code 45 Treatment Foster Care S9482 Family Stabilization Services T1005 Respite Services T1007 Behavioral Health Treatment Plan Update T1024 Resource Management Services T1502 Medication Administration PCG selected between one and ?ve of these procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid during calendar year 2012. In total, targeted review included 23,764 claims from 210 of the highest billed-for recipients across 15 providers. Random Sample Review Because behavioral health services typically feature high volumes of low-cost claims, PCG selected a statistically valid simple random selection of claims and extrapolated our ?ndings across the claims universe using standards consistent with those used by the US. DHHS Of?ce CONFIDENTIAL Page 19 State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP of Audit Services, endorsed by the Centers for Medicare and Medicaid Services (CMS), and supported by New Mexico Administrative Code. Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that papulation. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. All samples_c_onsisted_of 15.0 claims per provider and were selected from the entire universe of paid claims for each provider between July 1, 2009 and January 2013. CMS 010 set a minimum standard of 100 claims for use in extrapolation, thus the 150 claim sample size is more than adequate to meet the statistically valid threshold produced by RAT-STATS as well as compliance with the 010 standard. This approach allowed for a comprehensive view of billing practices that was representative of the provider?s clinical and billing policy compliance during this period of time. Samples were randomly selected using the GIG-developed statistical sampling software RAT-STATS. The steps to conduct this sampling process and overpayment extrapolation include: Step I - De?ne the universe population The universe was de?ned as the total set of claims paid between July I, 2009 and January 2013 from each reviewed provider minus any claims which were selected for the Targeted Review. PCG pulled these claim extracts universes) and retained them in a spreadsheet numbered 1 to where is the total number of claims. Step 2 - Determine sample size While the U.S. DDHS Of?ce of Audit Services commonly uses minimum sample sizes of 100 claims, PCG chose to review 150 claims to improve the precision of our samples. Step 3 Select the Sample Random selection of claims is necessary in order to produce a valid sample. in random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the universe at large. As a result, the sample allows an accurate portrayal of what is occurring across the universe. PCG used the GIG-developed RAT-STATS random number generator to identify the claim numbers to be selected from the universe spreadsheet. This RAT-STATS random number generation software was extensively tested by the National Bureau of Standards using 13 CONFIDENTIAL Page 20 A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTINC. Final Report GROUP certi?cation programs to ensure randomness and passed all l3 of these tests. Following this random number generation, RAT-STATS generates a seed number which serves as an auditable reference point should the numbers need to be re-generated at a later date. The speci?c steps used for selection of samples in this process include: 1. Using a random number generator (ex: generate a random number to be used as the seed associated withThe sample. 2. Open the RAT-STATS statistical software and navigate to Random Numbers>Single Stage Random Numbers. 3. Select ?yes? to ?Do you want to enter a seed number and input the seed number from above? lnput the desired number of claims for the sample in the Sequential Order Box. Enter the range of values in the Low Number (I) and High Number boxes. Output to an excel ?le and save as a backup. >395"? Using the random numbers spreadsheet, identify the claims from the universe to be included in the audit by selecting those line numbers that were pulled. Step 4 - Audit the Sample Each randomly selected claim was reviewed for compliance with New Mexico?s clinical and billing policies and to ensure the legitimacy of the state?s payment, as described in Section 4.4. The dollar values of any claims validated as non-compliant were classi?ed as overpayments. Step 5 Extrapolate the results The results of audits were extrapolated using RAT-STATS. PCG ?rst created two spreadsheets; one to record the detailed audit results sample item with the difference amount) and one to include the sampling details number of items in the universe and number sampled). Once this information has been entered and saved, PCG inputs this information into RAT-STATS. RAT-STATS identi?es the overpayment amount using the Lower Bound of the 90% con?dence interval, meaning that, in lay terms, there is a 95% chance that the actual overpayment amount (if all claims were to be audited) would be higher than the estimated overpayment amount The speci?c steps used for extrapolating the results of our ?ndings are as follows: CONFIDENTIAL Page 21 4% State of New Mexico ?g Human Services Department - i Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP I. Query the state?s claims data to pull the total claims universe for each provider and copy to Spreadsheet 2. Create a Spreadsheet #2 with ?ve columns: Stratum (column A), Paid Amount (B), Examined Amount (C), Sample Size (D), and Universe Size (E). 3. input the correct information into the appropriate column for each provider. 4. insert two columns-in the spreadsheercolumns-B and C. LII Save the spreadsheet using the naming convention Open RAT-STATS and go to Variable Appraisals -) Unrestricted Enter the total Universe Value from Spreadsheet Click Specify input File, choose Excel and choose the Spreadsheet On the next screen, choose Examined and Audited Values, and Output to Text File. Save the text ?le with the same naming convention as the excel ?le. 10. Enter the sample size of the case. ?3 1 1. Click OK twice, and then click Additional Summary info twice. 12. The recoupment amount is the 90% Lower Limit. Typically, extremely low rates of noncompliance result in poor precision. Therefore, if both the claims error rate and the paid error rate are less than extrapolation is not used and the overpayment amount is simply the sum of the sample overpayment amounts. 4.6 Key Case File Findings Case File Audit did not uncover what it would consider to be credible allegations of fraud, nor any signi?cant concerns related to consumer safety. However, review revealed a provider system in need of technical assistance, eSpecialiy considering the seismic shift that the state?s behavioral health system will undergo with the transition to Centennial Care in January 2014. Utilizing a statistically signi?cant extrapolation methodology, PCG identi?ed more than $33.8 million in overpayments to these 15 providers over a three year period from 2009-2012 (13.5% of total payments). CONFIDENTIAL Page 22 4% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Provider A Provider Provider Provider Provider Provider Provider Provider Provider 1 Provider Provider Provider Provider Provider Provider 0 $13,978,874 $9,495,054 $23,669,210 $35,786,267 $2,089,889 $897,468 $1 1 .08 1,469 $6,344,1 52 $7,480,070 52,870,455 ,373,845 $9.5 84,483 5 14,934,445 $77,493,302 $30,599,545 $4,327,784 34, 128,958 $772,0 16 I 38,735 $3,629,976 $7,856 $2,046,690 $6 I 2,663 $57.6 14 $228,309 1 .304, I 40 $2,757,585 $1,028,069 $9,262,71 1 $565,309 31.0% 43.5% 3.3% 8.8% 173.7% 0.9% 18.5% 9.7% 0.8% 8.0% 29.8% 28.8% 6.9% 12.0% 1.8% Totals $250.6 78,52 7 531 23. 7% $33,868,415 13.596 While each provider is unique with respect to clinical ?ndings, PCG identi?ed a few common themes across many of the [5 providers reviewed. Each provider has a speci?c section in the report that provides the detailed clinical ?ndings. Non-compliance with many New Mexico state rules and regulations was common. Provider-speci?c ?ndings are located within each provider's audit section. Generally, PCG found the following issues across providers: 0 Community Support Workers lacked evidence of completion of the required training per the service de?nition. 0 Safety/Risk Assessments were not completed or updated for consumers who were assessed to have current or past suicidal ideations (SI), homicidal ideations (1-11), self harm or domestic violence issues. 0 Assessments evaluations) were not up to date (within last 12 months) to determine if the consumer continued to meet the need of the rendered service. Incomplete critical information such as Five Axis diagnosis. I Substance abuse history was absent for most consumers with a dual- diagnosis of mental health and substance abuse. CONFIDENTIAL Page 23 . lhut?a" as State of New Mexico I Human Services Department ll Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 0 Treatment plans were not up-to-date and individualized per consumer. Updated treatment plans are necessary to determine any changes to goals/objectives in addition to progress or lack of progress by the consumer. Without continuously updated treatment plans, it is impossible to determine if the treatment interventions still meet the behavioral health needs of the consumer. Plans contained the same goals.?objectives for more than 12 months. Potential overutilization of services without documented justi?cation of the service related to extensive length of stay. Goals/Objectives were not measurable and did not document achievable target dates based on the consumer?s needs. Service-speci?cclinical interventions used to reach goals/objectives were absent. Discharge plans and estimated length of treatment were not documented for all consumers. Documented discharge plans were rarely individualized. 0 Consumer Documentation Consents for medications rendered were absent. Documentation frequently did not describe the clinical interventions, progress or lack of progress toward goals, and next steps in treatment. Interventions in the progress notes did not always link to the consumer?s treatment plan or support the program de?nition of the billed service. Progress notes did not contain a start and stop time or a duration that would enable a determination as to whether the billed time was accurate. Billed units did not match the units documented on the progress notes. intensive Outpatient Program progress notes did not contain the treatment modalities used as required in the service definition. Documented evidence of the required treatment team was absent for most team services. 4.7 Key Recommendations Below, PCG has compiled a list of recommended best practices that New Mexico should include in its payment rules and regulations. Many of these are already included in payment rules and regulations but appear not to always be enforced. PCG recommends that the policies be reviewed and strengthened clari?ed so there is common understanding among BSD and providers) and enforced by all payers (either the state or a contracted MCO). The recommended best practices are divided into case ?le components: assessments, treatment plans, and progress notes. CONFIDENTIAL Page 24 4% A State of New Mexico I I Human Services Department I I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Assessments Type of information Description identifying Information 0 The date of initial contact and admission date; 0 The consumer?s name and contact information (including address/phone and emergency contact information); The consumer?s age, self-identi?ed gender ethnicity, and marital status; 0 Information about signi?cant others in the consumer?s life including guardian/conservator or other legal representatives; 0 The consumer?s school and/or employment information; and, Other identifying information, as applicable such as Medicaid Identi?cation Number. Communication Communication needs are assessed for whether materials and/or service provision are required in a different format other languages, interpreter services, etc.). If required, indicate whether it was/will be provided, and document any linkage of the consumer to culture-speci?c and/or linguistic services in the community. Providers are required to offer linguistic services and document the offer was made; if the consumer prefers a family member as interpreter, document that preference. Service-related correspondence with the consumer must be in their preferred language/format. Relevant physical health conditions Relevant physical health conditions reported by the consumer or by other report must be prominently identi?ed and updated, as appropriate. Presenting problem/referral reason relevant conditions Presenting problem/re?ner! reason relevant conditions affecting the consumer?s physical health, mental health status and conditions living situation, daily activities, social support, etc.). Includes problem de?nitions by the consumer, signi?cant others and referral sources, as relevant. Special status situations Special status situations that present a risk to the consumer or to others must be prominently documented and updated, as appropriate. These might include imminent risk of harm, suicidal or homicidal ideations, self-injurious behaviors, or possible elopement. If a risk situation is identi?ed, the Treatment Plan must include how it is being managed. CONFIDENTIAL Page 25 A State?of New Mexico I Human Semces Department i Behavioral Health Provider Audits PUBLIC CONSULTING Final Report caour Consumer 's Consumer?s in achieving anticipated treatment goals consumer?s skills and interests, family involvement and resources, community and social supports, etc.). Medications. List medications prescribed by an MD employed by the provider, including dose/frequency of each, dates of initial prescriptions re?lls. Documentation of informed consent for medications is required. Medications prescribed by an outside MD must?be listed as above, per consumer or report; provide the name and telephone number. Allergies adverse Per consumer or by report, to any substances or items, or the lack reactions/sensitivities thereof. Substance use, past last Alcohol, caffeine, nicotine, illicit substances, and prescribed use/current over-the-counter drugs (as applicable). Mental health history Mental health history, including previous treatment dates and providers; therapeutic interventions and responses; sources of clinical data; relevant family information; and results of relevant ., lab tests and consultation reports (as applicable). C.) Other history As relevant, include developmental history; social history; histories of employment/work, living situation, etc. For consumers under age Include (or document efforts to obtain) pre-natal/ perinatal events, 18 and complete developmental history (physical, intellectual, social academic). Relevant Mental Status Includes signs and relevant to determine diagnosis and Examination plan of treatment. Five-axis diagnosis Five-axis diagnosis from the most current DSM (or 1CD), consistent with presenting problem, history, mental status examination, and/or other assessment data. Signature/Credentials/Date Signeture/Credentials/Date of the licensed person completing the Assessment. Assessments must be updated at least every 12 months or when there has been a signi?cant change in the consumer?s clinical behaviors. Treatment Plans Treatment Plans (aka Consumer/Life/Recovery/Care Plans, etc.) are plans for the provision of behavioral health services for consumers who meet the medical necessity criteria. Treatment CONFIDENTIAL Page 26 4% State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Plans must be developed from the Assessment, substantiate ongoing medical necessity, and be consistent with the diagnosis(es) that is the focus of behavioral health treatment. Strength-based and recoveryfresiliency focused treatment planning is best practice and strongly recommended. ol? lnlimnulim Dcsuriplion Timelines 0 Treatment Plan must be developed within 30 days of admission; 0 6-Month Treatment Plan Update: The treatment plan must be updated every 6-months to ensure that the most clinically appropriate interventions are being rendered to the consumer; and, - Other Updates to the Treatment Plan: The Treatment Plan must be updated whenever there are significant changes in the consumer?s presentation and/or situation that affect their planned treatment. Consumer Goals 0 Stated in own words, when possible. Mental health 0 Goals and objectives should be speci?c and measureable, and goals/objectives linked to the Assessment?s clinical analysis and diagnosis must be related to mental health barriers to reaching consumer?s goals). Provide estimated time frames (target dates) for attainment of both short and long term goals/objectives. Interventions Interventions and their focus must be consistent with the behavioral health goals/objectives and must meet the medical necessity requirement that the proposed intervention(s) will have a positive impact on the identi?ed impairments. Providers should indicate: 0 Service Interventions, which are the planned behavioral health services Individual - Interventions should be appropriate to the consumer?s diagnosis, age and intellectual needs; 0 Documented linkage of interventions to the rendered service de?nition; and, 0 ?Best practice? to also indicate clinician interventions, which are the provider?s actions during services to support the consumer?s progress toward goals/objectives ?Offer stress reduction techniques to reduce anxiety? or ?Support consumer to express unresolved grief to reduce depression?). CONFIDENTIAL Page 27 4% State of New Mexrco I I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Duration and Frequency - Service intervention duration and frequency should be noted, with target dates for each. Coordination of Care - lf applicable, it is ?best practice? to include an objective in the treatment plan regarding coordination of a consumer?s care with other identi?ed providers. Estimated Length of Stay/Discharge Plan 0 Should be completed. Signature/Credentials/Date - Should be completed. Evidence of the consumer?s degree of participation and agreement Evidence of the consumer?s degree of participation and agreement with the Treatment Plan should be addressed in the following ways: 0 The consumer?s (or legal representative?s) dated signature on the Treatment Plan is required; a If the consumer (or legal representative) is unavailable or refuses to sign the Treatment Plan, the Plan must include the provider?s dated/initialed explanation of why the signature could not be obtained, or refer to a speci?c Progress Note that explains why. In either case, include evidence on the Plan or in Progress Notes of follow-up efforts to obtain the signature; and, - If the provider believes that including the consumer in treatment planning would be clinically contraindicated, the Plan must include the provider?s dated/initialed explanation or refer to a speci?c Progress Note that explains why, and the reason must be supported by the clinical record?s documentation. Copy of the Treatment Plan - A copy of the Treatment Plan must be provided to the consumer (or legal representative) upon request and a statement to that effect must be either on the Plan or within other documentation signed by the consumer. Progress Notes Progress notes (including logs) are the evidence of a provider?s services to or on behalf of a consumer and relate to the consumer?s progress in treatment. Progress notes must contain the clinical details to support the medical necessity of each claimed service and its relevance to the prescribed treatment plan. In order to receive reimbursement for a service, there must be a complete progress note for that service. CONFIDENTIAL Page 28 A A FA. A A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Progress Notes must clearly relate to the behavioral health objectives and goals of the consumer as established in the Treatment Plan (versus, for example, a progress note that focuses on the mental health needs of a depressed mother in a family session, without addressing how her depression impacts the consumer/child?s mental health needs.) Each Progress Note must ?stand on its own? regarding medical necessity, identifying a clear link to the individualized treatment plan. Progress Notes must be entered into the clinical record within one (1) working day of each service provided. In the infrequent situation-when an emergency prevents timely recording of services, the service must be entered in the clinical record as soon as possible. The beginning of the note must clearly identify itself as a late entry for the date of service ?Late entry for date of service?). Signatures for late entries must include the date the note was written. Below are minimum requirements PCG recommends for Progress Notes: pc ol? Inl'ornmlion [Description Dates of Services a Date of service on which the service was rendered must be documented. Service Intervention - Service intervention or service code rehabilitation, collateral, behavior management service, medication management, etc. Location 0 Location of the service provided of?ce, home, community, school, employer, etc. Time 0 Time spent providing a service. The progress note must contain either a start and stop time or total duration of the rendered service. Documentation 0 Reason for the contact. - Assessment of consumer?s current clinical presentation. 0 Speci?c behavioral health/clinical interventions by provider, per type of service and scope of practice. 0 Consumer?s response to interventions. and limitations in achieving treatment plan goals/objectives. 0 Plans, next steps, and/or clinical decisions. If little or no progress toward goals/objectives is being made, describe why. Include date of next planned contact and/or next clinician action. Indicate referrals made. 0 Address any issues of risk. If risks are present, a risk assessment or ?no harm" agreement must be completed. - Signature/Credentials/Date of the person who rendered the service. CONFIDENTIAL Page 29 5. lT/Billing Systems Reviews 4% A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report caour S. IT/Billing Systems Reviews PCG Information Technology staff accompanied PCG audit teams for on-site audits for 15 New Mexico Behavioral Health Providers in February and March 2013. As mentioned before, review of information technology (IT) systems included examination of provider IT systems, their inputs, outputs, and claims processing. The purpose of the IT audit was to verify if evidence existed in the IT systems and procedures to support the preliminary audit ?ndings. The IT systems that were reviewed include each provider's: 0 Eligibility System 0 Prior Authorization System 0 Clinical Systems Electronic Health Records) I Rx System (if there is one in place) 0 Billing System Error types The IT audit examined three main ways in which error could enter the information lifecycle ?ow: 0 Human error in data entry or processing steps - Unintentional software processing error 0 Deliberate action taken to alter the records either by a human or computer so they do not match treatment given General Controls Control structure of the provider affects its IT operations. During the onsite audits, audit teams collected documentation in order to evaluate and document: 0 Organizational Controls decision ?ows within the organization - Data Center and Network Operations Controls how is the proper entry of data ensured and what is the procedure for error correction? - Hardware Software Acquisition and Maintenance Controls 0 Access Security Controls - how is the computer equipment, software, and data protected? What procedures are in place in the event of an unauthorized use? CONFIDENTIAL Page 30 2g 1 State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC EDITEULI INC. Final Report no Application System Acquisition, Development, and Maintenance Controls how is the reliability of information processing ensured? - Managerial controls- are the IT assets protected from unauthorized use? Systems Documentation After collection of IT documents, documentation thumb of the IT systems was analyzed. The IT Audit focuses on the Billing Lifecycle subset of the Healthcare Delivery Lifecycle: Healthcare Delivery Lifecycle This procedure outlines the steps necessary to audit the provider?s IT Health care billing system and determine how this fraud/abuse is being perpetrated in the billing lifecycle. The healthcare delivery lifecycle steps include: Bed facility; of?ce service; products appointment lnpatient/outpatient/o?ice services performed Patient discharged/of?ce visit concluded Medical record assignment of and CPT codes Bill is processed and submitted Bill is submitted to TPA/payer for processing Payment received Account follow up/collection neoprene-90's? IT Billing Lifecycle The IT Audit should consider the error types listed above for each step of the billing lifecycle. At a high level, the IT billing lifecycle is as follows: a. Claim is ?lled out by human either on a paper form or an electronic record that records information about a health care item delivered to a patient. b. An operator enters the claim data into the provider?s billing system. c. The system validates the entries, checks eligibility and performs actions according to system settings. d. The billing system processes the claim, updates the database and generates a bill. Review of information technology (IT) systems is a vital element of the audit process and included examination of provider IT systems, their inputs, outputs, and processing. The purpose CONFIDENTIAL Page 3 Her C) 45% State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC RDUP Final Report of the IT audit was to verify if evidence exists in the IT systems and procedures to support the preliminary audit ?ndings. IT Audit Process PCG developed an overall understanding of all providers? billing operations and systems. PCG documented the workflow from the provision of the service to the creation of a claim. To achieve this, PCG: - Analyzed each providers? healthcare information systems. This included all the systems that interact in the claim lifecycle, including intake, eligibility, prior authorization, health records, and billing systems, as well as relevant databases. 0 Performed a full review consisting of two major elements: a) b) Analyzing how the systems and databases work; what rules they use; how they interact; and who and built them, operates them, and maintains them. To this end, PCG requested all documentation regarding the information systems in place. Performing end-to-end tests for selected claims. PCG sought to follow claims selected for review across all systems and to compare system inputs and outputs for re-entered claims data in order to verify proper system performance. These claims represented a subset of the claims subject to clinical case review. These audit steps focused on identifying the following factors that could contribute to the billing irregularities: Weak security Unauthorized access to data and unauthorized remote access Inaccurate information and erroneous or falsi?ed data input Misuse by authorized end users Incomplete processing and/or duplicate transactions Untimely processing Communication system failure Inadequate training and support General IT Findings Generally, providers were helpful in explaining how their systems worked and in providing the requested documentation. However, because of system limitations and apparent software vendors centractual arrangements, there were several providers who could not provide the full range of requested documentation. CONFIDENTIAL Page 32 as State of New Mexico I I Human Services Department I, Behavioral Health Provider Audits Final Report I - The l5 providers audited use systems to handle their intake, eligibility, clinical record creation, billing creation and billing submission. Some providers use more than one system a Clinical Records system and :1 Billing system). The providers use the following systems for their clinical and billing functions: Anasazi: - Border Area Mental Health 0 Counseling Associates, inc. 0 The Counseling Center, lnc. - Families and Youth, lnc. - Partners in Wellness LLC 0 Southwest Counseling Center lnc. - Valencia Counseling Services Inc. - Southern New Mexico Human Development EMR Bear: 0 Hogares lnc. TeamBuilders Pathways El Perico: 0 Youth Development Inc. MediSoft: 0 Santa Maria El Mirador - Service Organization for Youth Inc. NextGen: - Presbyterian Medical Services Practima: 0 Hogares Inc. - Pathways 0 TeamBuilders Anasazi Software was not able to provide a complete audit record for billing. The software provides an adequate audit trail for the clinical portion, but not for billing. PCG staff was informed, through providers, that Anasazi Software would not provide any system documentation, claiming that it is proprietary. This includes: 0 User instructions/manuals/guides CONFIDENTIAL Page 33 ?g A State of New Mexico I I Human Services Department I Behavioral Health Provider Audits PUBLIC ggtilsumm Final Report 0 User training materials 0 Installation Instructions 0 System maintenance guides 0 System development documentation All providers utilize the Optum portal for authorizations, eligibility, and billing entry, and all providers use Optum Netwerkes as their ACH Automated Clearing House. PCG evaluated all the IT controls involved in the billing process from intake through to submission of the Claim during our audit. PCG found that the sophistication and controls in place were greater for the larger organizations. Some organizations they were more reliant on manual processes and institutional knowledge that had been built up over time. The size of the departments varies depending on the size of the provider and the number of sites they support. The SOphistication of the training for clinical areas and IT areas also varies between providers. CONFIDENTIAL Page 34 Appendices Audit Protocols Provider Audit I . PUBLIC CONSULTING GROUP State of New Mexico Human Services Department I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Audit Protocols New Mexico Human Services Department Behavioral Health Provider Audit and Policy Review February 26, 2013 CONFIDENTIAL Page 35 4% WW State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Contents 1. Background .. 37 2. Project Teams .. 42 3. Communications .. 43 4. Clinical and Case File Review Procedures . . . . . . . . . . . . . . . . . .. 44 4.1. Claim Sample Selection Methodology .. 44 4.2. Claim Review Methodology .. 45 5. IT Audit Procedures .. 48 5.1. Systems to Review .. 48 5.2. Error types .. 48 5.3. General Controls and System Documentation .. 48 5.4. Sampling . .. .. 49 5.5. IT Audit Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 49 Appendix 1 Case File Review Questions -- . .. 51 Appendix 2 IT System Audit Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 53 CONFIDENTIAL Page 36 State of New Mexico ?a I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 1. Background The New Mexico Human Services Department (HSD) has engaged Public Consulting Group (FCC) to conduct audits of a select group of behavioral health providers. Preliminary reviews and reports indicate potential service or?coding?issues. As a resultj?HSD has requested a comprehensive medical record and credentialing audit. Speci?cally, the following items have been identi?ed for further exploration: - Cross billing at different locations for the same member potentially overlapping time; uncertainty as to who rendered the service (if rendered at all); - Insuf?cient documentation; - Cross billing multiple codes and double billing individual and group therapy); - Upcoding individual therapy (compared to the average time billed per code in the peer group); i - Excessive billing for rehab; incl. requesting authorization for a consumer on medical leave; - Suspicious high volume days per one code; overbilling for inappropriate codes; rehab billed for large units on a given date to one clinician; excessive hours per day billed by practitioner; excessive hours of service billed per patient per code; billing for services duplicative in nature; - Identifying Provider as the rendering clinician; - No medical necessity reviews to determine basis for long-term - Forging clinician records to incorporate more time than truly performed; - Out of home placement services outside norm of service; doubtful medical need; - Billing outpatient services the same day as bundled services. As a result of the preliminary ?ndings, PCG has been tasked with conducting onsite audits of selected providers to examine case ?les, IT systems and processes, and adherence with compliance protocols, and to examine existing relationships among providers. The onsite visits are expected to entail interviews with relevant provider staff, collection of hard or electronic copy documents related to the above mentioned areas, review of clinical data and examination and manual testing of IT systems. CONFIDENTIAL Page 37 State of New Mexico I i I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report emu The onsite visits will be supplemented by desk reviews at a location separate from the provider site. Findings resulting from desk reviews may necessitate follow up communication with providers to clarify and/or request additional information. The documentation ?ndings will be provided in a ?nal report to the Department of Human Services. The ?nal report will state the nature, timing, and extent of the audit work performed, as well as the ?ndings, conclusions, and recommendations and any reservations, quali?cations or limitations of scope that IT audit team has with respect to the audit. Provider Obligations Several documents outline provider reSponsibilities regarding the provision of access to facilities, systems, and ?les and other documentation. These documents include: 0 New Mexico Medicaid Provider Participation Agreement 0 UBH Facility Participating Provider Agreement 0 Optum Health New Mexico Provider Manual The relevant sections from each document are excerpted below. New Mexico Medicaid Provider Participation Agreement Excerpted from Article 1, Obligations of the Provider, which states that the Provider shall: 1.19. Furnish immediately to the DEPARTMENT or its AUTHORIZED AGENTS, the US. Secretary of Health and Human Services, or the Medicaid Fraud Control Unit, at no cost, access to records in any format requested and any information regarding payments claimed by the PROVIDER for furnishing services to eligible recipients. 1.20. Permit announced and unannounced inspection of facilities or the of?ces and other locations used in the provision of services for billing and to eligible recipients by the US. Secretary of Health and Human Services, the Medicaid Fraud Control Unit, and the DEPARTMENT and its AUTHORIZED AGENTS. Failure to comply with this provision constitutes a violation of federal and state law and may result in immediate withholding of any pending or future payments. If records are requested by mail, the PROVIDER CONFIDENTIAL Page 33 4% A State of New Mexico I Human Services Department (J Behavioral Health Provider Audits PUBLIC CONSULTINL Final Report cacur' shall furnish the records within two (2) to ten (IO) business days of the receipt of the request or as provided in the request. Assist and cooperate in any review, inspection or audit conducted in conformity with the terms of this AGREEMENT. UBH Facility Participating Provider Agreement Excerpted from the New Mexico Statewide Behavioral Health Program Funded by the Behavioral Health Collaborative Regulatory Requirements Appendix, Section 4: Optum Health Requirements: 4.7 OptumHealth may periodically conduct a review, such review to include an audit, of Provider?s records to determine Provider?s compliance with State and Federal codes, rules, regulations and requirements, as well as with the Agreement. Provider agrees that Provider shall cooperate as necessary in any such review, which may include, but are not limited to, the following: (1) Federal and State audits; (2) Encounter Validation Studies - Provider shall participate in any required Center for Medicaid and Medicare Services and/or OptumHealth data validation studies and other validation studies as may be required. Any and all Covered Services may be validated as part of the studies; (3) Review of Financial Statements and Other Documents Provider shall supply annual ?nancial audits, A-l33 audits, periodic ?nancial statements, and other documents as requested by OptumHealth; and/or (4) OptumHealth and State will regularly audit and monitor ?nancial stability of Provider, requests for additional ?mds, or requests for funds as a result of claims reimbursement issues. Optum Health New Mexico Provider Manual Excerpted from the section entitled ?Audits: On-site, Treatment Records, Financial Records?: OptumHealth representatives visit practice locations and facilities to conduct a variety of on-site audits, including but not limited to, routine clinical quality audits, environmental site audits, quality of care audits (to address concerns identi?ed through Critical Incident reporting or consumer complaints, for example) and ?nancial viability audits. Environmental audits may be conducted ?x ?1 x, 1? CONFIDENTIAL Page 39 A A 4? State of New Mexico I I Human Services Department I I Behavioral Health Provider Audits PUBLIC Final Report as part of the routine quality audit processor, for facilities without national accreditation or state certi?cation it may be part of the credentialing and recredentialing process. Any facility, regardless of accreditation, may be subject to an On-site Audit for any potential quality of care concerns brought to the attention of OptumHeaIth. During an On?site?Audit, charts are reviewed for documentati of diagnosis treatment plan, veri?cation of services provided to members and other elements. You are expected to maintain adequate medical records on all consumers. Prior to a scheduled audit visit, you will be noti?ed of the speci?c types of charts that will be reviewed. Failure to document services and/or dates of services may lead to a request for a Corrective Action Plan. Financial viability audits include a review of speci?c records to assess ?nancial stability with a goal of strengthening the viability for the long-term. Some examples of records that are reviewed as part of the ?nancial audit are income statements and balance sheets. As with any audit, you will be noti?ed of the speci?c requirements prior to the review. Audit tools are based on standards set forth by the State of New Mexico, National Committee on Quality Assurance (NCQA), The Joint Commission (formerly JCAHO) an independent, not-for-pro?t organization that evaluates and accredits more than 16,000 health care organizations and programs in the United States, and OptumHealth. Audit tools are available for reference on optumhealthnewmexico.com. Treatment Record Documentation Requirements in accordance with your Agreement, you are required to maintain high quality medical, ?nancial and administrative records related to the behavioral health services you provide. These records must be maintained in a manner consistent with the standards of the community, and conform to all applicable laws and regulations including, but not limited to, state licensing and/or national certi?cation board standards. In order to perform required utilization management and quality improvement activities, may request access to such records, including, but not limited to, claims records and treatment record documentation. You are permitted under HIPAA Treatment, Payment or Healthcare Operations to provide requested CONFIDENTIAL Page 40 4% Stateof New Mexico . I I I I Human Serwces Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP records as contractually required. In accordance with HIPAA and the de?nition of Treatment, Payment or Healthcare Operations, you must provide such records upon request. Federal, state and local government or accrediting agencies may also request such information as necessary to comply with accreditation standards, laws or regulations applicable to OHNM and its Payors, customers, clinicians, and facilities. OHNM may review your records during a scheduled On-Site Audit or may ask you to submit copies of the records to OHNM for review. An On?Site Audit and/or Treatment Record Review may occur for a number of reasons, including, but not limited to: 0 Reviews of facilities without national accreditation such as The Joint Commission, CARF or other agency approved by OHNM Audits of high-volume clinicians Routine random audits Audits related to claims coding or billing issues Audits concerning quality of care issues identi?ed by OHNM or brought to attention by members, family members or their representatives Audits of clinicians with a home of?ce 0 Audits related to a member complaint regarding the physical environment of an of?ce or facility 00000 00 The audits may focus on the physical environment (including safety issues), policies and procedures, and/or thoroughness and quality of documentation within treatments records. OHNM has established a passing performance goal of 85% for both the Treatment Record Review and On-Site Audit. On?Site Audit or Treatment Record Review scores under 85% will require a written Corrective Action Plan (CAP). Scores under 80% require submission of a written CAP and a re-audit within six months of the implementation of the CAP. Guidelines contained in this section are subject to change. CONFIDENTIAL Page 41 4% State of New Mexico I Human Services Department Behaviorai Health Provider Audits PUBLIC CONSULTING Final Report GROUP 2. Project Teams Each project team is expected to be comprised of three to ?ve individuals including the following speci?c roles: 0 Team Lead: The team lead will be responsible for overseeing the general operation of the onsite visits. Speci?c functions include: Initiating onsite communication with provider staff 0 Facilitating the entrance discussion, including explaining the purpose of the visit, expectations for provider assistance and actions to be carried out/protocols to be followed by the audit team during onsite time Coordinating team activities to ensure that team members are connected with the appropriate provider staff members and are able to collect the required information 0 Conducting interviews with key provider administrative and clinical staff 0 Facilitating exit discussion and communicating any additional information/next steps to provider 0 Administrative Support: Administrative support staff will have primary responsibility for data collection and storage and will provide as needed support to the other team members. Speci?c functions include: Physically collecting documentation given by the provider, which may include pulling case ?les 0 Scanning, logging and uploading all collected ?les 0 Participating in interviews with provider staff and documenting these interviews 0 Information Technology Lead: The IT lead will have primary responsibility for working with the provider?s IT staff to analyze IT systems, their applications and functionality. Speci?c functions include: 0 Collecting documentation regarding IT infrastructure and all software systems currently in use, speci?cally those used for submitting claims to Optum and capturing other relevant clinical information 0 As appropriate, manually testing system functionality to determine the link between system inputs and outputs and to identify any areas of concern CONFIDENTIAL Page 42 as State of New Mexico I I Human Services Department I I Behavioral Health Provider Audits PUBLICCONSULTING Final Report GROUP 3. Communications Providers identi?ed for audits will not be given advance notice of the audits; rather, the team will arrive on site on the scheduled day unannounced. The team lead will request to speak with the Executive Director or other designee and will request an immediate entrance conference, at which the team lead will present a letter from HSD explaining the purpose of the audit and provider expectations regarding compliance. Along with the letter, the team lead will provide documentation containing the identities of the randomly selected recipients (including service type and dates of service) as well as a list of documents that the provider will be required to make available to the audit team. Requested documents pertaining to the individual components of the audit are outlined in subsequent sections. Once onsite, the team lead shall ensure the appropriate level of communication with provider staff. Upon arrival, the team lead will conduct an entrance conference with the designated provider representative (or his or her designee) and other relevant provider staff. The items to be covered in the entrance conference include: 0 Provide hard copy of letter of authority to conduct audit 0 Provide claims list for review 0 Discuss sc0pe of audit--recipient and staff records review to ensure policy/regulation compliance 0 Request staff ?les related to recipients/claims identi?ed for review 0 Discuss space needs and estimated time onsite 0 Establish provider contact for questions onsite As appropriate, the team lead will address provider questions related to the nature, purpose and scope of the audit. Information shared in this regard will adhere to HSD guidance on this issue, and questions that cannot be addressed by the team lead will be referred to the appropriate HSD contact. The team lead shall ensure that speci?c audit team members are connected with the proper staff to address their speci?c component of the audit process. All audit documentation collected onsite will be scanned or saved to a secure laptOp and logged, including but not limited to the above mentioned documents as well as session and supervisory notes, manuals, reports, flowcharts, correspondence, observations, plans, test results, meeting minutes, computer records, and data ?les. PCG has deveIOped a detailed system for logging all CONFIDENTIAL Page 43 A State of New Mexico Human Services Department I Behavioral Health Provider Audits PUBLIC ESDIIJJEULTING Final Report information collected onsite and ensuring that the necessary documentation is seamlessly captured and recorded. Prior to departing the provider site at the conclusion of the onsite portion of the audit, the team lead will hold an Exit Conference to validate that PCG has received all requested documents and will be reviewing them for compliance through the desk review process. As appropriate, any next steps for theprovider will be?communicated at this point. 4. Clinical and Case File Review Procedures Clinical and case ?le reviews will be a major part of audit process. Our administrative and clinical staff will apply rigorous analysis to all paid claims selected for review. Our methodology will seek to provide assurance that paid claims are consistent with administrative, credentialing, and clinical requirements set forth in the state?s Medicaid regulations. Upon arriving at provider sites, PCG will present provider staff with the list of claims patient name, service rendered, date(s) of service, etc.) and ask staff to pull the appr0priate medical records for the claims in question. The PCG team will bring portable scanners to provider locations and upload the appropriate documents to a secure, HlPAA-compliant database from which the appropriate reviewer will download the documents for review. 4.1. Claim Sample Selection Methodology PCG will execute a two-pronged approach to the selection of claims for review. The ?rst prong will be a full, statistically valid random sample of all claims for each provider. PCG will randomly select 150 claims from each provider for a full case ?le review. It is critical in selecting samples for case ?le review to ensure randomness so that the review is fair to the provider and is demonstrable as such to impartial parties during the due process phase as many such reviews are subject to appeal. During visit to Optum Health, Optum staff provided PCG with all paid claims data for providers subject to this review. PCG extracted the claims data and uploaded it into a SQL database for analytical review, validation, and ultimately sample selection. PCG will employ RAT-STATS, an Of?ce of Inspector General (01G) approved statistical sampling package to drive the sample selection for this engagement. PCG has employed RAT-STATS in multiple engagements and is well-versed in all facets of the program. The program produces a ?seed? number to demonstrate the randomness of the sample should a provider appeal on the grounds that claims were selectively targeted and do not represent the entirety of their claim universe. The statistically valid random sample will CONFIDENTIAL Page 44 0 State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC EEDIIJIEULTING Final Report enable PCG to extrapolate any ?ndings over the entire universe of claims for a provider in determining overpayment amounts. The second prong of our approach will be to conduct a targeted claim selection process. Through its data analytics process and through tips from whistleblowers, OptumHealth has identi?ed potentially outlying claims for each of the providers under audit. Several of the procedure codes identi?ed as potentially being overbilled are codes billed in 15 minute increments and are billed over an extended period of time. It is often concerning to payers of health care claims when the units of service do not decrease over time within these codes for a given individual. It is sometimes a red ?ag that a provider is billing for that service for that individual in an ?auto- pilot? mode or that the consumer is not making the desired progress. For these types of services, it is often dif?cult to diagnose a billing issue by reviewing only a single date of service. Through a targeted claim selection process, has isolated the consumers for whom the most units have been billed of these procedure codes over a 12-month period (Calendar Year 2012), removed those claims from the universe of claims subject to random sampling, and will request documentation associated with claims submitted on behalf of those consumers and audit the entire length of stay. This will allow our review team to ensure through examination of treatment plans, service authorizations, progress notes, and other documentation that the services are, in fact, taking place and the high level of service is necessary for that consumer given the diagnosis and goals of the individual. For each provider, we have identi?ed the 2-3 such procedure codes with the highest spend and have selected the 5 consumers with the most units billed. It should be noted that the targeted claim selection process is not statistically valid and cannot be extrapolated to claims other than those claims that are reviewed. It is intended to provide an extensive, thorough review for a small number of consumers so that HSD can determine if a more widespread review is warranted. 4.2. Claim Review Methodology Case Files As stated above, the noti?cation from HSD to providers will identify the clients whose case ?les have been randomly selected for audit and request that the provider have available all related service documents for review not limited to: assessments - evaluations 0 Treatment plans/person-centered plans 0 Service notes/progress notes CONFIDENTIAL Page 45 A A State of New Mexico I Human Services Department I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 0 Consents Referrals, and Authorizations/service orders The team lead and clinical lead will request the provider walk through the layout of the clinical record with the team to identify provider speci?c documents such as assessments, notes, consents etc. and will conduct interviews with key clinical staff and practitioners as necessary. Provider Credentialing In addition to documentation regarding the services provided, PCG will request from the provider personnel documents related to the quali?cations for staff that rendered services to selected recipients. This documentation will include at a minimum the relevant provider?s: License to Practice Academic/Professional Degrees(Master?s, Bachelor?s, High School, GED) Resumes Certi?cations (Board Certi?cation, Certi?ed Peer Specialist) Trainings Supervision Notes, if required by service Criminal Background Checks(speci?c to Respite Care, Residential, Foster Care) In addition to staff-speci?c information, PCG will request agency documentation related to personnel policies and procedures for maintaining staff quali?cations. The goal of this credentialing review is to address questions including: Does the rendering practitioner have a current valid license to practice? Did he or she receive the appropriate training to provide the service rendered? What is the status of clinical privileges at the institution designated by the service provider as the primary admitting facility, if applicable? Does a valid drug enforcement agency (DEA) or controlled substance registration (CSR) certi?cate exist, if applicable? As with all gathered documentation, all ?les will be scanned, logged and uploaded to the secure website. Desk Audit Steps Once the onsite data collection process has been concluded and case ?les have been examined for completeness and accuracy, the reviewing clinician will be noti?ed that case ?les are ready CONFIDENTIAL Page 46 .r 44% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTINC. Final Report caour for review. The documents will be pulled down from the secure website for clinical review. All cases will be reviewed using an audit tool containing a broad set of questions speci?cally related to excessive billing, overutilization, duplicate billing, coordination of care, upcoding, and renderer of service. In addition to the areas above, certain service types will contain speci?c questions in order to ensure a comprehensive program review. Examples of speci?c questions are outlined in Appendix 1 although the?list is not exhaustive as each claim?s review will be driven by the speci?c procedure code for that claim and the questions asked will be unique to requirements for billing under that procedure code. Some of the key questions that will be asked of each claim include: 1. Do the units paid match the units of service documented for the sampled procedure code? Was the amount of rendered units appropriate for the recipient? (excessive billing) 2. Was the service delivered medically necessary and appropriate (overutilization)? 3. Does the documentation support, or relate to, the rendered service? i.e. Does the documentation match the description of the services associated with the procedure code? 4. Does the procedure code match the documented duration of time spent serving the member for the encounter billed (upcoding)? 5. Were multiple units/encounters billed for the same procedure code for the same recipient in the same day? For each claim, the reviewing clinician will provide a response to each clinical question. Possible reSponses are: 0 NofNot Met 0 Not Applicable - Yes/Yes Met Comments are required for NofNot Met and will be followed by the NMMAC Regulations, NM Service De?nitions, and Level of Care citation verbiage. CONFIDENTIAL Page 47 as A State of New Mexico 1 Human Services Department II I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 5. IT Audit Procedures Review of information technology (IT) systems is a vital element of the audit process and will include examination of provider lT systems, their inputs, outputs, and processing. The purpose of this lT audit is to verify if evidence exists in the systems and procedures to support the preliminary audit ?ndings. Upon the completion of the IT audit, a report will be provided. 5.1. Systems to Review The lT systems that should be reviewed include provider?s: 0 Eligibility System 0 Prior Authorization System 0 Clinical Systems Electronic Health Records) - Rx System (if there is one in place) 0 Billing System 5.2. Error types Error could enter the information lifecycle flow through three main ways. These must all be accounted for in the audit procedures for all of the systems listed above: 0 Human error in data entry or processing steps - Unintentional software processing error 0 Deliberate action taken to alter the records either by a human or computer so they do not match treatment given 5.3. General Controls and System Documentation General Controls Control structure of the provider affects its IT operations. The following should be evaluated and documented: 0 Organizational Controls decision ?ows within the organization a Data Center and Network Operations Controls how is the proper entry of data ensured and what is the procedure for error correction? 0 Hardware Software Acquisition and Maintenance Controls CONFIDENTIAL Page 48 A A A 44% A State of New Mexico I I Human Services Department 0 i Behavioral Health Provider Audits PUBLIC Final Report - Access Security Controls how is the computer equipment, software, and data protected? What procedures are in place in the event of an unauthorized use? 0 Application System Acquisition, Development, and Maintenance Controls how is the reliability of information processing ensured? Managerial controls- are the IT assets protected from unauthorized use? Systems Documentation Documentation for each of the IT systems should be gathered and analyzed. Appendix 2 provides a checklist for systems documentation. 5.4. Sampling Due to the possibly large volume of claims to analyze, audit sampling may be applied when necessary. Audit sampling is the application of an audit procedure to less than 100% of the population to evaluate audit evidence within a class of transactions (claims) for the purpose of forming a conclusion concerning the p0pu ation. The sample size creates a risk that the conclusions may be different from the conclusions that would have been reached based on the (3 whole population. The most common types of sampling used are systemic sampling and random sampling. Random sampling ensures equal chances of selection, whereas systematic sampling involves using a ?xed interval between selections every 10?h sample; ?rst interval has a random start). The sampling objectives and methods should be documented. Documentation should include the source of the population, the sampling method used, sampling parameters, items selected, details of audit tests performed, and conclusions reached. 5.5. IT Audit Processes The audit steps protocol and checklists in Attachment 2. The information below provides additional background on the healthcare delivery lifecycle and the IT billing lifecycle. Healthcare Delivery Lifecycle This procedure outlines the steps necessary to audit the provider?s IT Health care billing system and determine how abuses might be perpetrated in the billing lifecycle. The healthcare delivery lifecycle steps include: a. Bed facility; of?ce service; products b. appointment CONFIDENTIAL Page 49 as A State of New Mexico I Human Services Department Behavioral Health Provider Audits N) EEOTIEULTING Final Report c. Inpatient/outpatient/of?ce services performed d. Patient discharged/of?ce visit concluded e. Medical record assignment of and CPT codes f. Bill is processed and submitted g. Bill is submitted to TPA/payer for processing h. Bill is received i. Account follow up/collection IT Billing Lifecycle The IT Audit should consider the error categories listed in Section 3.1 for each step of the billing lifecycle. At a high level, the IT billing lifecycle is as follows: a. Claim is ?lled out by human either on a paper form or an electronic record that records information about a health care item delivered to a patient I b. An operator enters the claim data into the provider?s billing system A c. The system validates the entries, checks eligibility and performs actions according to system settings d. The billing system processes the claim, updates the database and generates a bill. Review of information technology (IT) systems is a vital element of the audit process and will include examination of provider IT systems, their inputs, outputs, and processing. The purpose of this lT audit is to verify if evidence exists in the IT systems and procedures to support the preliminary audit ?ndings. Upon the completion of the IT audit, a report will be provided. CONFIDENTIAL Page 50 0 State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Case File Review Questions Below is an incomplete list of questions utilized in the audit tool: Responses: Questions ('mmnculs Was a evaluation completed as appropriate contains a treatment history whether substance abuse, mental health, or both)? Does the evaluation contain all ?ve DSM-IV axes and is it signed by a licensed clinician? If the identi?ed treatment is for mental health, is a mental health screening present and complete? If the identi?ed treatment is for substance abuse, is a history of smoking, alcohol use, and substance use documented? This must include present and past use, frequency and duration of use, administration method, as well as any abuse of medications, whether prescribed or over the counter. Does the record document a risk assessment appropriate to the level of care and population served which includes the presence or absence of suicidal or homicidal risk? Was there documentation of continuity of care, consultation, and referral prior providers, consultants, Probation/Parole Of?cers, Employee Assistance Programs, housing, employers, Courts, Department of Vocational Rehabilitation, ancilliary and other non-behavioral health providers?) Was the treatment plan signed by a treatment team licensed practitioner? Was the treatment plan individualized per person including the speci?c service provided with appropriate goals and objectives? Does the treatment plan estimate the length of treatment and contain a discharge plan? Are the treatment interventions consistent with the individualized treatment plan? CONFIDENTIAL Page 51 as A 4% A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Was the service delivered medically necessary and appropriate (overutilization/length of stay)? Were the delivered interventions appropriate to the diagnosis, age, and intellectual needs? Does the service note document progess or lack of progress toward treatment goals/objectives? Does the documentation support, or relate to, the rendered service (service de?nition)? Were multiple units/encounters billed for the same procedure code for the same recipient in the same day? Are the encounters billed supported by documentation of medical necessity in appropriate amount, duration and scope? Were the billed services rendered by qualified practitioners? If so, was the practitioner identi?ed as rendering the service (instead of providers/T Does the procedure code match the documented duration of time spent serving the member for the encounter billed (up coding)? Was the amount of rendered units appropriate for the recipient? Were medication codes billed appropriately and non-duplicative? Do the notes re?ect target rationale for medications, treatment recommendations, and response to medications? Was the written informed consent for medication documented? ls there evidence of an evaluation of the recipient's response to the prescribed medications and adjustments made as needed? Does the record document what medications have been prescribed, the dosages of each, and the dates of initial prescriptions or re?lls? CONFIDENTIAL Page 52 A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP - Appendix 2 - IT System Audit Checklist To be ?lled out for each audit site separately Section I: Audited entity information Name Address 1m (SSN, DEA etc) Organization Section II: Audit team information Name Date Signature CONFIDENTIAL Page 53 AA ?ll PUBLIC CONSULTING GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Section Documentation gathered (YIN) No Document name Comments - Process documentation of development and maintenance, including: 1. Plans, schedules, reports used in the development/ customization process 2. Process quality documents 3. Organizational and project standards 0 Documentation of current system settings, including: 1. System architecture (also for each program in the system) 2. Description of components and their functionalities 3. Rules 4. Logic and automatic actions applied to data entries/claims 5. System maintenance guide 6. Validation and how it related to the requirements CONFIDENTIAL Page 54 State of New Mexico I I Human Services Department 0 Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 0 Documentation of system factory settings 1. [document - End-user documentation (a3. manuak) 1. [document 0 System administrator documentation 1. Functional description 2. System installation document 3. Introductory manual 4. System reference manual 5. System administrator?s guide Other documentation . [document 1] CONFIDENTIAL Page 55 A A f?A State of New Mexico I I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Section IV: IT Hardware Software System information in the/bllou'ing IT system information to be gathered ?-om documentation and interviews Can do Initial pass pre-w'sit ??om documentation. 0 Make a full list of all servers and all PCs at a location using the following format for each machine. Inventory ID: Location: Type (server/PC) and name: Staff who can access: Access level description: I. [name 2. Hardware: [description] Software installed (inlc. anti-virus) Version and licensing info 1. [item Services exposed to the Internet Reason for exposure . [service 1] - Make afull list of network equipment Firewall/switch Firmware version Con?guration info Network access permissions What ?3 allowed into the network 1. [item 1] CONFIDENTIAL Page 56 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP 0 Document network connections . [description] Section V: Audit steps The audit steps focus on identifying the following factors that could contribute to the billing irregularities: - Weak security - Unauthorized access to data and unauthorized remote access 0 Inaccurate information and erroneous or falsi?ed data input - Misuse by authorized end users 0 - Incomplete processing and/or duplicate transactions I Untimely processing 0 Communication system failure - Inadequate training and support For ggc_h of the IT systems below execute the full set of audit steps: 3) Eligibility System b) Prior Authorization System (PAS) c) Clinical Systems Electronic Health Records) (1) Rx System (if there is one in place) e) Billing System CONFIDENTIAL Page 57 ?gs Hill r? PUBLIC CONSULTING GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report AUDIT STEPS PROTOCOL IT System: [name and type billing, eligibility, PAS, etc.] No Audit Step Completion Date Person Responsible Notes Compare paper or electronic claims to the submitted bill and any intermediate reports created by the system. Record the claims that are compared and make copies of any discrepancies. On a more general scale, compare the input to the system and the output from the system for correctness Verify that the training material, courses and instruction practice good processing. Identify the training procedures to train employees on the system use Verify that any user modi?able setting is correct on the billing system. Especially settings might change ?nal billing amounts List all system components and processes that can interact with the database of record Identify system user authentication/login procedures and what is currently implemented Identify system administration capabilities and what is currently implemented CONFIDENTIAL Page 58 C) PU BLIC as CONSULTING GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report identify backup procedures and what was implemented List Disaster Recovery procedures. identify if it has ever happened Analyze Audit trails/logs generated by system. Identify if any of them relate to the potential billing discrepancies iO. identify if any batch processes that are used to upload data Determine if any media is stored offsite and document it identify and interview company that deveIOped and maintained the IT billing system. Ask the following questions: Does the system offer the ability for users to modify billing amount calculations? Do the users of the system have access to source code? Do the users of the system have ability to modify any portion of the database including SQL, stored procedures, report tools, software responsible for creating billing statements or reports? l3. Interview person or people who use or manage the billing system and ask the following questions: CONFIDENTIAL Page 59 4% State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report caour a Who has access to alter system settings? Who has the ability to change the source code? Who has the ability?to change the. data in the database? Does everyone have their own login? e. Are logins shared? Is there a log of users who sign in and use the system? g. [5 there a database transaction log? Is there an application transaction log? [5 everyone who enters data into i. the system required to go through a training course? . How are data entry errors detected by the system? k. Is there a data entry error log? [5 there documentation that l. explains the data entry validations implemented by the system? Identify the programmers and 14. support staff that have access and can modify the billing system Additional audit steps CONFIDENTIAL Page 60 as g? State of New Mexico Human Services Department 0 Behavioral Health Provider Audits CONSULTING Final Report GROUP If Fhere is direct online access to the provider billing system additional audit steps can be performed: Verify that the billing system 15. process and screens matches the documented functionality Verify that the billing program securityfeatures work as planned l6. and only authorized users can make entries or changes to the IT system l7. Verify source code controls Verify any online reports 18. generated match the database values Verify IT system controls in the C) processing of the claim and ensure the completeness and accuracy of the transaction processing, authorization and validity. These include: 19. Data Capture Controls ensures that all transactions are recorded in the application system, a. transactions are recorded only once, and rejected transactions are identi?ed, controlled, corrected, and reentered into the system Data Validation Controls ensures b. that all transactions are properly valued Processing Controls ensures the proper processing of transactions CONFIDENTIAL Page 51 AA A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Error Controls ensures that errors are corrected and d. resubmitted to the application system at the correct point in processing CONFIDENTIAL Page 62 4% a A State of New Mexico I Human Services Department 0 I Behavioral Health Provider Audits PUBLIC EEOTIEULTING Final Report Section VI: Audit step execution documentation it"hen discrepancies are identified they should be documented and attached to this document The person generating the documentation should date and Sign the attachments I. For instance, if an input claim form for a patient does not match the submitted bili, then a copy of the original claim and a screen shot ofthe billing information should be captured. 2. Images for portions of audit trails that show an unauthorized change should be captured. 3. Any tests that identify that the user actions are not being stored properly in the database of record should be documented and screen shots should capture the process utilized. No Document description Date Person Notes Responsible CONFIDENTIAL Page 63 Border Area Mental Health Services Clinical Narrative IT Narrative Entergrise Narrative . PUBLIC CONSULTING GROUP A A A A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP BORDER AREA MENTAL HEALTH Case File Audit Dates of Onsite Review March 6 13, 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $2,046,690 Actual Longitudinal Overpayments $179,903 Total Overpayment Amount $2,226,593 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate 71% 35% Border Area Mental Iicalih Prm'ider Scorecard Sigwo? mm A an; This scorecard result translates to the following Risk Tier: Risk Tier T) pes of Findings Recommended State Action 3 Signi?cant ?ndings, 0 Provide trainings and clinical including signi?cant assistance as needed. CONFIDENTIAL Page 64 A A A $335 State of New Mexico ll Human Services Department Behavioral Health Provider Audits PUBLIC CONSLELI INC. Final Report (.noul' quality of care 0 Potentially embed clinical management ?ndings. to improve processes. 0 Potential change in management. Provider Overview Border Area Mental Health Services is the largest provider of behavioral health services in southwest New Mexico and has seven locations across the region. Within these locations, Border Area delivers behavioral health services including outpatient services, family programs, substance abuse services, comprehensive community support services/case management, and community correction program services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 3 Claims Paid FY12 3 Claims Paid Audit Period BHSD 1,228,308 4,727,240 CYFD 85,398 478,450 Medicaid FFS 48,927 229,135 Medicaid MCO 1,460,105 5,069,573 NMCD [5,598 120.357 Other 243,51 1 727,869 Grand Total 3,081,847 11,352,623 Audit Team Observations 0 An entrance conference was held approximately 30 minutes after PCG arrived onsite at Border Area Mental Health Services (BAMHS). -, was out of the of?ce on the day PCG arrived and our entrance conference was held with? and ?assumed responsibility for the coordination of the document collection and worked with administrative and clinical staff. 0 PCG began to receive case ?les on the second day of our visit. CONFIDENTIAL Page 65 A A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC I INC Final Report BAMHS staff provided PCG with hard copies of documentation and PCG scanned the ?les and saved them to a laptop. 0 supplied PCG with documents related to the BAMHS billing system and procedures and did an informal demonstration of the system. 0 Initially, BAMHS provided a user guide to Anasazi but upon consultation with the lieensor requested that PCG sign a document that we would not distribute or view the document for competitive reasons. PCG purged the document from our ?les. - BAMHS was cooperative throughout the process but was disorganized in their collection of documents. PCG received multiple copies of many of the documents and many documents were not submitted. 0 Clinical Reviewers noted the following general ?ndings: 0 For Foster Care and Treatment Foster Care, time sheets were often the only documents verifying placement of a child no progress notes or other goal- tracking documentation was received for review. Safety/Risk Assessments were not completed or up-to-date for multiple consumers who were assessed to have current or past suicidal ideations (SI), homicidal ideations (HI), self harm or domestic violence issues. Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were incomplete of critical information. Treatment plans were missing, not up to date, and/or not individualized per consumer. Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and ?fty (150) random date of service claims for July I, 2009 through January 31, 2013. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: CONFIDENTIAL Page 66 4% State of New Mexico I I 5 Human Services Department 0 Behavioral Health Provider Audits IING Final Report Procedure . f" Claims Claims Code Program Description Claims Claims ?ed Claims .led Reviewed Reviewed 8 Failed Diagnostic 9080] Evaluation 5 561 0 0 0.0 A 90804 Outpatient?20-30 minutes 2 87 0 0 0.0% 9080F?"0utpatient?4F50 minutesm'29' 0 0.0% 90808 Outpatient?75430 minutes I 79 0 0 0.0% 90847 Family Therapy 1 80 0 0 0.0% 90853 Group Therapy 14 347 0 0 0.0% 90862 Medication Management 6 411 0 0 0.0% 80015 Intensive Outpatient Program 6 705 0 0 0.0% H0031 Mental Health Assessment 5 1,783 0 0 0.0% H0041 Foster Care(Shelter) I 2 1,200 0 0 0.0% 0 H2010 RN Medication Monitoring 2 I38 0 0 0.0% Crisis Intervention Services I 1 l2 0 0 0.0% H2015 H0, HN, 36 2,417 34 2,272 94.4% H2017 Rehabilitation 5 6 5 2 291 40.0% H2033 Multi-Systematic Therapy 8 1.740 0 0 0.0% 85145 Treatment Foster Care 3 480 0 0 0.0% S9482 Family Stabilization Services 5 270 0 0 0.0% T1007 Behaworal Health Treatment 9 1,019 8 909 88.9% Plan Update Grand Total 150 14,073 44 3,471 29.3% Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any specific areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: 0 CONFIDENTIAL Page 67 A ll gill" PUBLIC. CONSULTING GROUP Recipient DOS H2015 Assessment Screening Treatment Plan Pass Sewice Delivery Pass Progress Notes Pass Billing NIA Staffing Fail Consent Forms NIA Pharma NIA Other NIA State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Comments Missing document: assessment unable to determine quali?cation to provide service based on intormat?nn in ?le. H2015 Pass Pass Pass NIA Fail NIA NIA NIA - not quali?ed per staff roster. H2015 - Pass Pass Pass Pass NIA Fail NIA NIA NIA Missing documentation: quali?ed per staff roster. H2015 Fail Pass Pass Pass NIA Fail NIA NIA NIA Unable to read signature of provider on evaluation. Missing documentation: H2015 Fail Fail Fail Fail NIA Fail NIA NIA NIA Missing documentation: no treatment an in . No safety risk assessment documented on progress note. 1 not on staff roster. she has documents in staff ?le. is not on staff roster or in staff file. not quali?ed per stall roster. H2015 Pass Pass Pass NIA Fail NIA NIA NIA Mlssini documentation: educati?-?l not quali?ed per staff roster. H2015 Pass Pass Pass Fail NIA Fail NIA NIA NIA Billing indicates three units. and per progress note. the duration of this was 0:15 min=1 unit. Missing documentation education. Not quali?ed per staff roster - I H2015 Pass Pass Pass Fail NIA Fai NIA NIA NIA No risk assessment on progress note. Missing documentation: not on staff roster. H201 5 Pass Pass Pass Pass NIA Fail NIA NIA NIA -not qualified per staff roster. H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA Missing mmemnz?m? not quali?ed per staff roster. H201 5 Pass Pass Pass Pass NIA Fail NIA NIA NIA qua: .pers Pass Pass Pass Pass NIA Fail NIA NIA NIA Per comprehensive. consumer has been in treatment since CONFIDENTIAL Page 68 Raf-x f? State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report GROUP 11I20109 at least to the time of the claim above 4I25112. There is an annual intake update dated 1/23/12 and another on 12101110. No information on one conducted in 2011. H2015H0. HN. 8315.6; LOC 8.315.159; Service De?nition) Per staff list, this provider not meet the quali?cations. H2015 a Fail Pass Pass Pass NIA Fail NIA NIA NIA ?mm? CONFIDENTIAL Page 69 0 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report . . . Resipient Assessment Treatment Servrce . Consent Progress Billing Staffing Pharma ther Comments Not Forms es H2015 . Pass Pass Pass Pass NIA Fail NIA NIA NIA -not quali?ed per staff roster. Missing documentation: assessment. - unable to determine quali?cations to provide service from DOS i' Screening Plan Delivery H2015 Fail Pass Pass Pass NIA Fail NIA NIA NIA not quali?ed per staff roster. H2015 Fail Pass Pass Pass NIA Fail NIA NIA NIA the provider on progress note and is not quali?ed T0 or. . . Missing documentation: not on staff roster or in H2015 Fail Pass Pass Pass NIA Fail NIA NIA NIA Sta" qudi?ca?ons me. quali?ed per Sta? roster. Missing documentation: No comprehensive assessment found in ?le. Missing documentation: No treatment plan in ?le. Missing documentation Progress note documents Suicidal intent H2015 Fail Fail Fail Faii NIA Fail NIA NIA NIA expressed in session and homicidal intent expressed in session but there is no new safety risk assessment in fiie. Client shot and killed rto this date. Missing documentation: educa' Suicidal intent is documented as being expressed. progress note H2015 Pass MA NIA Fa" NIA Fail NIA NIA NIA does not indicate that the sennce plan, danger assessment or the safety prevention plan was addressed. _ot quali?ed per staff roster- H2015 . Pass Fail Pass Pass NIA Fail NIA NIA NIA Unable to determine quali?cations basedon?ie- H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA -resurne states'no degree'. Disclaimer indicates that client refused to complete the assessment for substance abuse. Missing document H2015 Fail Pass Pass Fail NIA Fail NIA NIA NIA CONFIDENTIAL Page 70 PUBLIC CONSULI INC A ?ll as State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report assessment. Note indicates one hour 4 units and billing is for 6 units. missing documentation: education. not qualified per staff roster. H2015 H2015 H2015 H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA Unable to open-?le. Pass Pass Pass Pass NIA Fail NIA NIA NIA Pass Pass Pass Pass NIA Fail NIA NIA NIA Not quali?ed per staff roster. Pass Pass Pass Pass NIA Fail NIA NIA NIA -not quali?ed per staff roster. CONFIDENTIAL Page 71 A PUBLIC CONSULTING GROUP Recipient DOS H2015 Assessment iScreening Fail Treatment Plan Pass Service Delivery Fail Progress Notes Fail Billing NJA Staffing Fail Consent Forms NIA Pharma NIA Other NIA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Comments No support services documented as being provided on date of service. Progress note documents telephone call. No interventions documented on progress note. No safety assessment documented on progress note. Nothing in the progress note demonstrates medial necessity for this billing. Missing documentation-not on staff roster. H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA -not quaii?ed per staff roster. H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA H2015H0, HN. 8315.6; Loc 8.315.69; Service De?nition). H2015 Pass Pass Pass NIA Fail NIA NIA Missing Document: -Wovider. is not found in the list or in provider ?le. H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA - not quali?ed per staff roster. H2015 Fail Pass Pass Pass NIA Fail NIA NIA NIA not quali?ed per staff roster. unable to open tile. H2015 Pass Fail Fail Pass NIA Fail NIA NIA NIA Missing document: treatment plan. Not quali?ed per staff roster. H2015 Pass Pass Pass Pass NIA Fail NIA NIA NIA .Provider CSW does not meet quali?cations. H2017 Pass Pass Pass Pass Fail Fail NIA NIA NIA Rehabilitation-(ch 3.31.5.3; Service De?nition); - IN STAFF LIST AS NOT MEETING ALL REQUIREMENTS: Rehabilitation NMAC 8.3.15.3; Service De?nition); in staff list as not meeting ail requirements. CONFIDENTIAL Page 72 NIH PUBLIC CONSLILI IN: . GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2017 T1007 T1007 T1007 T1007 - T1007 71007 T1007 11007 Pass Pass Pass Pass Fail Fail NJA NIA NIA Missing documentation: no comprehensive team list. Provider - does not meet all the quali?cations as per staff list. NIA Fail NIA NIA NIA NIA NIA NIA NIA Treatment plan has staff signatures dated 2119/2010 and- -signarure dated 3110110. There is nothing on the actual treatment plan that demonstrates it was updated on the date billed for service. NIA Fail NIA NIA NIA NIA NIA NIA MIA Missing document: treatment plan for date of service billing. NIA Fail NIA NIA NIA Pass NIA NIA NIA NIA NIA Fail Fail NIA NIA NIA NIA NIA NIA Fail Fail NIA NIA NIA NIA NIA NIA Not for 6l2110?T1007?Behavioral Health Treatment Plan Update?(Sewice De?nition). Missing documentation: - -tot quali?ed per stall roster. I-ot quali?ed per staff roster. no education dowmented for her. No signature of supervisor present on treatment plan. NIA Fail NIA NIA Fail Fail NIA NIA NIA Treatment plan Is signed and dated on 109112. NIA Fail NIA NIA NIA Fail NIA NIA NIA Missing dowmenl: treatment plan. NIA Fail NIA NIA NIA Fail NIA NIA NIA ?GOT?Behavioral Health Treatment Plan Update?(Servioe De?nition). CONFIDENTIAL Page 73 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report l?lliilJC COVSLILI l\ f. GROUP Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the pepulation without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling FrameSize: Total number of claims from universe?of claims from which the?sampl was selected. Sampling Unit: The entire claim amount. Time Period: 7/1/2009 - 1/31/2013 Sample Size: Sample size is [50 claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Border Area Mental Health Services Sample Size 150 Total Paid for Sample $14,073 Sampling Frame Size 117,492 Number of Sample Claims with Overpayments 44 Using Lower Bound of the 90% $2,046,690 Longitudinal File Review PCG selected between one and five of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Page 74 era?3% I?Lllilli. State of New Mexico Human Services Department Behavioral Health Provider Audits niicni- Final Report . . . 5 Value Free Program of Cases Claims 3 Claims Claims Chin?s Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed H2015 5 317 27,678 317 27,678 100.0% CCSS H20 1 7 5 993 l27,886 352 41,843 35.4% Rehabilitation Multi- H2033 Systematic 5 517 10.775 515 110.383 99.6% Therapy Grand Total 15 1,827 266,339 1,184 179,903 64.8% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 12 FPS Therapist 25 Nurse 3 2 Rehabilitation 2 Unknown/Other 7 Total Staff Reviewed 52 Page 75 A A State of New Mexico I I Human Services Department m?m- CONSULHM. Behavioral Health Provider Audits Final Report lT/Billing Systems Audit System Overview Border Area Mental Health utilizes the Anasazi System for most of its medical records and billing. The system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really super?cial, such as: The way menus are customized to be displayed per the user roles, How user roles are de?ned, The customization and scheduling of reports and 0 When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most agencies in the Rio Grande system stay one to three updates behind the most recent. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. Anasazi would not allow Border Area Mental Health (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. Bill Processing On a simple level, after services are provided to the client, the clinician updates the ?le with notes and the time and date of encounter. The Anasazi software processes this information and calculates the number of units that the service should be billed for, and what code should be assigned to the service, using the service provided and start and stop times of the servrce. The service is processed by the Anasazi system and transformed into an 837 billing format, which is uploaded to Optum health through the Optum Netwerkes system. IT Contacts and roles Page 76 5% A State of New Mexico Human Services Department mm (OWN Behav1oral Health Provider Audits uncur- Fmal Report 2% #5 Application Controls -'System Administration and Segregation of Duties UsenRoles System Admin Group: Can add users and con?gure data sheets for health plans and services. Administrative Group: Can con?gure data sheets for health plans and services. Medical Records and Intake Groups: Records Clerks and Intake Staff have appropriate administrative levels of access to records (primarily administrative and demographic records and read only for clinical information). Clinical Group: All clinicians who bill are in the Clinical Group. They can enter clinical service provision to the system. CQI Group: Ql Manager is in this group. Clinical Supervisors Group: Clinical Supervisors. Rio Grande Supervisors Group: Supervisory staff from Rio Grande Behavioral Health Services are provided with supervisory roles due to the management services agreement with Border Area: I. 2. 3. Auditors Group: No staff at Border Area currently have the Auditor Role, but Border Area has established four Auditor accounts should auditors need access. and Weaknesses The Anasazi so?ware offers sequestration of clinical information so that users? roles determine the kind of information each user may have access to on a per client basis. For example, a front of?ce clerk may have access to certain demographic information. 0 Each clinician enters his own billing information. - Anasazi software allows for members of a group therapy session to arrive and leave at different times, allowing for more accurate billing of group services. Page 77 A fr-n?: A State of New Mexico II I Human Services Department IIUBUC Behavioral Health Provider AUdilS Final Report - The Anasazi system that the provider uses records and tracks clinical records. 0 The audit trail for the clinical record portion of the system is extremely complete and easy to generate. - Have extensive training and training videos for Anasazi system. Have a training database set up separate from the production database. 0 The IT department has written SO-IOO reports to check different medical ?eld billing value accuracy that they run on all entered bills before they are submitted for payment. o?There is an?audirtrail forthe'ir [Thelpdesk issues that have been resolved. 0 Have a disaster recovery plan. Border Area Mental Health exPerience a fire a couple of years ago that destroyed the majority of their paper records. Since then they have instituted a strong disaster recovery plan. Weaknesses: The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. The 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 can make any changes to billing with no audit trail. 0 The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered The Anasazi system does not report on the audit trail for the billing part of the system. 0 There is no complete audit trail of the entire clinical and billing transaction that is guaranteed to correspond to what is billed to Medicaid Recommendations 0 Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. Page 78 A a State of New Mexico Human Services Department [tum Behavioral Health Provider AUdltS enour Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Border Area Mental Health Services (BAMHS). PCG began by locating legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on BAMHS. PCG located and reviewed audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches on the organization or related individuals. Because of the closely interrelated companies, PCG reviewed BAMHS and two other related companies simultaneously Mimbres Regional Mental Health (provides administrative staffing to BAMHS) and Mimbres Properties (leases real estate to BAMHS). Audit Observations Border Area Mental Health consists of three related exempt organizations: 0 Border Area Mental Health Services Mimbres Regional Mental Health and - Mimbres Properties. 0f the three, BAMHS is the provider organization; is an organization that provides administrative staf?ng to and Mimbres Properties leases real estate to BAMHS. in addition to leasing real estate to BAMHS, Mimbres Properties has signi?cant unrelated business income in the form of rental income. Page '79 A A State of New Mexico i I I i Human Services Department Punuc; consuumc, Behavioral Health Provider Audits GROUP Final Report BAMHS publishes the least transparent ?nancial documents of all the organizations reviewed. There is extremely weak disclosure of pertinent information for evaluation purposes. These three organizations are governed by three separate boards of trustees, however, with small exception; the trustees are the same individuals. These individuals do not appear to have ?nancial connections with the organizations. Key Staff Border Aron Mental Health Frank Van Gundy Director Patricia Chavez Secretary/ Treasurer Margaret Vesper Director Sam Tapia President Claire Leonard Vice President Himln'cs Regional Mental Health Patricia Chavez Secretary/ Treasurer Margaret Vesper Director Sam Tapia President Claire Leonard Vice President Jeannette Helton Helton Director Claire Leonard Secretary/Treasurer Margaret Vesper Director Sam Tapia President Patricia Chavez Vice President Financial Relationships All three organizations have signi?cant transactions with a local company, Atlas Resources, although there is some variance in annual reporting with this contractor. Atlas Resources is an employee leasing organization, 1570209 located at 2009 Eubank NE, Albuquerque, NM and owned by Jimmy Daskalos and Nick Kapnison. Both men are involved in a number of companies and restaurants in the Albuquerque area and have a number of real estate holdings. They purchased the former Lovelace Hospital property and have subsequently leased the Page 80 A AA State of New Mexico Human Services Department mm ?msmluu? Behavioral Health Provider Audits Final Report as property. At one point, local media reported that the facility would be leased to physician practice groups. BAMHS contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources. Unlike other provider organizations, amounts paid by the organization to for these services are not disclosed. Rio Grande is a provider sponsored network and each organization?s board members serve as rotating members of the board. While Rio Grande Behavioral Health Services receives fees from its members, has also distributed various grants back to its members. In addition, BAMHS may contract with Rio Grande Management, LLC (ROM), for management services, although it is not disclosed in ?nancial documents. These likely include legal services, and the provision of executive management. Providence Service Corporation fully owns Rio Grande Management Services. Providence is a large, for pro?t, national, corporation providing government sponsored social services directly or indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. Typically, the executive director of this organization would be an employee of Providence Service Corporation. Kathleen Hunt is the Executive Director of BAMHS. She is also a director of which is typical for members of the Rio Grande provider group. For these reasons, we believe that she is likely to be employed by Providence Service Corporation and that BAMHS contracts with ROM for her services as well as the afore mentioned management services. Summary of Findings and Recommendations Findings Recommontlations Because staf?ng is paid by Atlas Resources, This is highly unusual and it is recommended compensation is not disclosed in reports that that be required to disclose signi?cant compensation by individual leased through Atlas Resources. Those individuals should be reviewed for associations with other organizations and individuals. exempt organizations typically ?le. It is further recommended that Mimbres Properties disclose detailed source information for unrelated rental income, including tenants, leases, and cash receipts. Major contracts, such as those with Rio Full disclosure of all signi?cant contracts Grande Behavioral Health Services and Rio should be reported on the organization?s Form Page 81 4% State of New Mexico Human Services Department PUBLIC- CONSULHNG Behavioral Health Provider Audits Final Report ae?? um ll Grande management are presumed, but not 990. fully disclosed. List of Key Documentation Reviewed Document/Source Year (if applicable) Audiied-Financial Statemenm 2012. 20l 1 Provider Organizational Chart Current Form 990 (Nonprofit ?ling) 2012, 2011 Federal Tax Filings 2012, 201 I Page 82 551?: A State of New Mexico Human Services Department liuul Behavioral Health Provider Audits hllOUl' Final Report Balance Sheet 2010 Assets Cash and equivalents 3 2,908,484.00 Grants and Contracts Receivable 69l,246.00 Note Receivable 628,456.00 Furniture and Fixtures 580,578.00 Less depreciation (474,750.00) Total Assets 4,334,014.00 Liabilities Accounts Payable l49,460.00 Building Fund payable 3 306,158.00 Grants payable 935,238.00 Annual Leave payable 106,234.00 Total Liabilities 1,497,090.00 Net Assets 2,836,924.00 Total Liabilities and Net Assets 5 4,334,014.00 Page 83 A PUBLIC CONSULI INC moul- as Income Statement Revenue Behavioral Health Services Division Children Youth and Families Dept. Local Grants and Contracts Program Fees Interest Income Net Asset release Total Revenue Expenses Program Services Total Expenses Change in Net Assets Net Assets, beginning of year Net Assets, end of year 2010 1,297,302.00 653.8 I 8.00 364.00 ,88l,64 I .00 5 - 4,866,297.00 4,509,619.00 4,509,619.00 356,678.00 8 2,480,246.00 2,836,924.00 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Page 84 Counseling Associates Inc. Clinical Narrative IT Narrative Enterprise Narrative PUBLIC CONSULFING GROUP gs State of New Mexico . Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP COUNSELING ASSOCIATES BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March 6-l2, 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $2,757,585 Actual Longitudinal Overpayments $210,548 Total Overpayment $2,968,133 Scorecard results are as follows: 0 Random Sample Compliance Rate Longitudinal Compliance Rate l. ounsellng A Provider Scorecard Significant .a 0n- Cv?W?h'mW vanadium This scorecard result translates to the following Risk Tier: Risk Tier T) pes of Findings Recommended State Action CONFIDENTIAL Page 85 A A ?z?s State of New Mexico I Human Services Department Behavioral Health Provider Audits If IINC. Final Report (.Iloul? 3 Signi?cant ?ndings, 0 Provide trainings and clinical including signi?cant assistance as needed. quality 0f care 0 Potentially embed clinical management ?ndings- to improve processes. 0 Potential change in management. Provider Overview Counseling Associates, lnc. is the largest provider of behavioral health services in Chaves and Eddy County, New Mexico. Within these locations, Counseling Associates delivers behavioral health services including; outpatient services, comprehensive community support services (CCSS), multi?systemic treatment (MST) community correction program services and substance abuse services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 5 Claims Paid FY12 5 Claims Paid Audit Period 1311313 1,257,543 4,21 1,293 CYFD 64,477 245,513 Medicaid FFS 39,333 181,107 Medicaid MCO 1,692,032 5,052,958 NMCD 22,174 1417.755 Other 2,581 3,517 Grand Total 3,078,240 9,842,147 Audit Team Observations 0 Upon arrival at 9 am, was at Carlsbad site. The PCG audit lead was noti?ed that was traveling back to Roswell immediately. The entrance conference took place late morning. 0 CAI staff immediately began to compile the documents. PCG received its ?rst documents in the afternoon of Day I, and received documents steadily during the onsite audit. CONFIDENTIAL Page 86 0 AA A Hill I PUBLIC CONSULI th; GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 Clinical Reviewers noted the following general ?ndings: Random Date of Service Claim Review 0 Safety Assessments were not always completed for consumers who were assessed to have current or past suicidal ideations homicidal ideations self harm or domestic violence issues. Safety/crisis plans were often completed months after the initial assessment when the concern for safety was revealed. Diagnostic Reviews often showed con?icting dates (difference of several months) related to completion and authorization signatures by clinician and supervisor. Comprehensive Clinical Assessments appear not to be up to date with current information. Treatment plans were not up to date and individualized per consumer. Progress Notes/Recipient Documents were inconsistent across staff and programs. 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 random audit sample and the resulting ?ndings: Procedure . . will": Claims 5 ?flue Claims Code Program Description Claims Claims Failed Claims Failed Reviewed Reviewed Failed 90801 th'afm D'mm" 1 137 0.0% Evaluation 90806 Outpatient?4540 minutes 19 1,324 0 0 0.0% 9084? Family Therapy 3 238 0 0.0% 90853 Group Therapy l3 324 0 0 0.0% 90862 Medication Management 11 749 0 0 0.0% 99214 Of?ce/Outpatient Visit 1 19 0 0 0.0% H0015 Intensive Outpatient Program 7 528 0 0.0% H0031 Mental Health Assessment 3 664 0 0 0.0% H2010 RN Medication Monitoring 28 1,044 0 0 0.0% CONFIDENTIAL Page 87 59:2: A f'r?R? State of New Mexico i Human Services Department Behavioral Health Provider Audits PUBLIC CONSLILI INC Final Report (?our H2014 Behavior Management Services 4 528 4 528 100.0% H2015 HO, HN, 24 1,614 24 1,614 100.0% H2017 Rehabilitation 18 1.726 18 1,726 100.0% H2023 Supported Employment 1 34 a 0.0% Servrces H2033 Multi-Systematic Therapy 8 1,143 0 0 0.0% Q3014 Telehealth Facility Fee/Code 2 45 0 0 0.0% T1 007 Behavnoral Health Treatment 5 625 625 I 000% Plan Update T1024 Resource Management Services 2 20 2 20 100.0% Grand Total 150 10,818 53 4,512 35.3% Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 88 A 4% Hill PUBLIC CONSULTING H2010 H2014. H2014 H2014 H2014 H2015 II II (HUDUP Pass NA Fail Pass NA NA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report The servrceswere billed signed by but. the note was Pass Pass Fail Fail Fail Pass NA NA Progress note documents receipt and ?ling of lab results. When added up the number of units bilied for three sessions on this dos 101212012 adds up to 14 unit or 15 units- seems like an under billing for these services. Progress note documents receipt and ?ling of lab results. Pass Fail NA Pass NA Fail NA NA NA The treatment plan is not speci?c for this cti ton thi of service. The quali?cations for the provider, are missing according to the statf roster list. Fail Fail NA Fail NA Pass NA NA A more in depth safety assessment was warranted but not documented. Only one intervention by EMS worker is documented in over 6 hours. Unable to support medical necessity of units billed based on progress note. Fail Fail Pass NA Pass NA NA Documentation of SI and attempts at Suicide documented in "1212010 assessment. stating attempts ?eariier this year?. Assessntent narrative does not document talking to parent about safety issues with consumer. Crisis plan is not documented until 6I10I2. Unrealistic, no measureable, "complete remission of Fail Fail NA Fail NA Fail NA NA Missing any none documented continuity of care services. No documentation of parents or guardians belng included in interventions. No length of time documented to adrieve goals of. 'improved attention..behavioral control. pro social behaviors for one year.? Unable to support the medical necessity of units billed based on the res note. Missing document quali?cations for Pass Pass Fail NA Fail NA NA No safety assessment documented. Review of staff roster CONFHDENTIAL Page 89 r?a Ill PUBLIC COVSULI INC. lilii State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report resulted designated as not meeting quali?cation requirements. H2015 Pass Pass Fail A review of staff roster resulted in designated as not meeting quali?cation requirements. H2015 3 Pass Pass Fail Review of statt roster resulted in ing designated as not meeting quali?ation requirements. H2015 Fail H2015 Pass Fail Fail Fail Pass The assessment does have boxes checked regarding SI a no harm contract was documented. narrative states consumer does not currently have SI. HI thoughts. There are no speci?c 0088 goals. objectives or interventions documented on treatment plan. Documentation re?ects of?ce visit. No safety assessment is documented. Progress note states service as discharge coordination; there is not another progress note for initial intake. one hour after this session. Unable to support 6033 services prior to intake and creation of treatment plan. - is shown as not meeting quali?cations per review of staff roster and related support documents. A team eating was documented in the progress note as well as a telephone call with the consumer. The treatment plan is not speci?c to this client?s needs. H2015 1. Fail Fail Pass Unable to discern it the contact with the hospital staff is in person or on the phone, according to the documentation. The docume tation does not support the units cited based on the informa supplied. Assessment is outdated by more than a H2015 Pass Pass Fail year. Go are not speci?c to the treatment n. Missing documented quali?cations for CCSS work. Missing document quali?cations for to pericrrn 6088 work. CONFIDENTIAL Page 90 gas ll PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report l?l2015 Pass Pass Fail Pass NA Pass NA NA NA Does nail list location. H2015 Pass Fail Pass Pass NA Fail NA NA NA Missing ocument Quali?cations for mis? non-spe as to CCSS interventions and goals. H2015 Pass Pass Fail Fail NA Fail NA NA NA Missing documentation of a progress note unable to support ?iled on the DOS. Review of staff roster resulted in designated as not meeting quali?cation H2015 Fail Fail Fail Fail NA Fail NA NA NA There are no documents other than a progress note dated for not the dos which was 1211412012. Tetephoned the discharde information to another agency. Discharge coordination is dominliented. Review of staff roster resulted in - being designated as not meeting quali?cation requirements. H2015 Pass Pass Pass Pass NA Fail NA NA NA Can not verify the quali?cation of the provider on this 008. H2015 Pass Pass Fail Fail NA Fall NA NA NA There is no progress note documented for this DOS. H2015 Fail Fail Fail Fail NA Faii NA NA NA There is no progress note documented for this DOS. Missing quali 'ons for Missing qualifications for The assessment documents that the consumer has present HI, and had SI the prior week. with a serious attempt at suicide in the past. A crisis plan is not documented until 2 months later. Also no follow on related to duty to warn. A Speci?c CCSS needs were not documented for this dos. H2015 i Fail Pass Pass Pass Fail NA NA NA Missing Pocumeniation uali?cations tom that is an aka for The ASI are documented. but the tool is not documented. CONFIDENTIAL Page 9] State of New Mexico Human Services Department I Behavioral Health Provider Audits PUBLIC CONSULI Final Report GROUP .. . Consent Progress Billing Staffing Pharma Other Comments Notes Forms Recipient Assessment Treatment Service DOS lScreening Plan Delivery Unable to determine from the documentation it the consumer was present during this meeting. There is a ccncem as to whether other attendees at meeti also billed for their services. Review of staff roster resulted being designated as not meeting quali?cation requirements. At date of assessment. 8l24l2010. documentation states consumer had active SI. There is no documentation of a no harm plan. a crisis plan or follow up on the St. A crisis plan was signed on 312512011. The clients discharge was coordinated via the phone and a another facility. Missing a treatment plan. No documentation of any documents for this consumer. No quali?cations are documented for Wt. Missing document quali?cations for H2015 Pass Pass Fail Fail NA Fail NA NA NA A progress note for this date of service was not documented. H2015 Fail Pass Fail Fail NA Fail NA NA NA H2015 Pass Fail Fail Pass NA Pass NA NA NA H2015 Fail NA Fail Fail NA Fall NA NA NA H2015 Pass Pass Pass Fail NA Fail NA NA NA A treatment plan was not documented. Progress note documents a phone call to another facility re: consumer discharge from H2015 Fail Fail Fail Fail NA Pass NA NA NA hospital. Unable to support number of units billed based on documentation. Assessment documents hospitalization for SI, a crisis plan is not dowmented. There is no safety assessment documented for this DOS. Review of staff roster resulted in -being designated as not H2015 Fail Pass Pass Fail NA Fail NA NA NA meeting qualification requirements. The assessment does not have boxes related to SI. HI tilled in; narrative deson'bes child who runsinto traf?c. A crisis plan was initiated. H2015 Pass Pass Pass Pass NA Fail NA NA NA Veri?cation of experience needed for staff providing services. CONFIDENTIAL Page 92 A easel-?s hill PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0110312012 H2015 Pass Pass Pass Fail Fail NA NA NA The billing hours were documented as being 1 hour 19 minutes which enuats 5 units. billed for 6 units. Missing document H2015 Pass Pass Pass Pass NA Fail NA NA quali?cations form Review of staff roster resulted being designated as not meeting quali?cation requirements. H2017 H2017 Fail Pass Fail Fail Fail Pass Pass Fail Fail Fail Pass Pass NA NA NA NA NA NA The goals are outdated and the intervention is the same generic interve 'on on all treatment plans with PSR. A visit a to a park and it are documented, otherwise there is no other informa as to where the services were rendered. The date of the diagnosis review is The date the diagnosis was established is 811912005. Unable to discern if consumer has been in trea ent at CAI since 2005 from the documentation. The document's that contain ?quatitications are missing. The goal is dated for 6I1912007 and it states, 'buitd problen} solving skills? but there is no progress noted in the documentation. Goals are dated in 2007: Abstinence - goals as stated in TP have been met, Leisme skills! problem solving! med management etc - documented that consumer attends sporadically, goal stated for PSR is abstinence from alcohol using generic intervention docu ted on all treatment plans. No quali?cations for - - PSR service needs are not described. Objectives date back to 2007 with no documentation of progress. H2017 Fail Fail Pass Pass Pass Fall NA NA NA Assessment does not document a need for PSR services, individual and group counseling is suggested in assessment. However. assessment documents state that PSR is occurring. A treatment plan was not documented for this 008. According to CONFIDENTIAL Page 93 Hill ll PUBLIL CONSLILI GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report the staff roster provided the practitioner, missing qLali?cations. H2017 H2017 H2017 H2017 H201 7 H2017 Pass Fail Pass Pass Pass Pass NA NA NA Treatment Plan does not include speci?c interventions that will promote Basic Living Skills Development, Skills Training. Therapeutic Socialization. A separate PSR plan is not Pass Fail Pass Pass Fail Pass NA NA NA documen ed. is not on Staff Roster. Treatment Plan does not include speci?c interventions that will promote Basic Living Skills Developnlenl. Skills Training, Therapeutic Socialization. A separate PSR plan is not documented. Pass Fail Fail Pass Pass Pass NA NA NA The client attended services at an of?ce and at the 'Eastem New Mexico Fair Disability day.? Treatment Plan does not include speci?c i erventions that will promote Basic Living Skills Develo ent. Skills Training, Therapeutic Socializatpn. A separate PSR plan is not documented. Fail Fail Pass Pass Pass Pass NA NA NA Goals were initiated 3118I2008. and they are outdated for this DOS. The Dx. are dated 2004 and 2007. assessment dated S?nmnable to discern the updates. The treatment plan is non- c. "Promote more effective personal functioning and community involvement" was the goal for Substance Dependence, medication management. excessive fear and social isolation. Pass Pass Fail Fail Fail Pass NA NA NA Progress note documents consumer socidized then tell, unable to supporl group intervention. Fail Pass Pass Fail Fail Pass NA NA Assessrn i only documents the need for alcohol abuse treatment Question is PSR is appropriate for this client. No interventi are documented regarding the PSR. Unable to support units billed based on progress note provided. which refers to consumer as "she" and provides brief explanation of intervention. There are no quali?cations found on the provider quali?cations list rol- CONFIDENTIAL Page 94 0 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Ti?il?ii . Pro-r: Recpaent Assessment Treatment Service Consent Progress Billing Staffing Pharma Comments Co-rlr: DOS Screening Plan Delivery Notes Forms diagnoses is Alcohol Dependence, with no treatment goals to maintain sobriety are in the Treatment Plan. Intervention described as, "skills training to promote more H2017 Pass Fail Pass Pass Fail Pass NA NA NA effective5person at". Missing documentation quali?cations for -There is non- specific service, not indhridualized for the client. Objective is stated as "therapuetic recreation to in?uence mood.? The client has a history of traumatic brain injury and epilepsy this medical need for PSR. The PSR is not on the treatment plan. The PSR is not on the treatment plan. The PSR is not on the treatment plan. Progress note documents CCSS Fail Fail Fail Fail Fail Fail NA NA NA servicesiin the home. Progress note documents CCSS services in the home. Progress note documents CCSS services in the home. Ptogress note documents CCSS services in the home. Progress note documents CCSS services in the home. The PSR is not on the treatment plan. This plan is only consistent with generic intervention. ?Skills training in a group format by a rehabilitation specialist or other staff to promote more effective personal functioning andlor community involvement" Unabte to support units billed with documentation. Unable to discern what, 'pate in independence day" means. Roster. The treatment plan does not mntain speci?c objectives a generic goal was established 10/11/2010. There is no documentation and no case note in the ?le. There is H2017 Pass Fail Fail Pass Fail Pass NA NA NA no documentation and no case note in the ?le that addresses the appropriate interventions. H2017 Pass Pass Pass Pass Fail Pass NA NA NA There is no documentation of education of licensure tor-? l-l2017 Pass Fail Pass Pass Fail Pass NA NA NA CONFIDENTIAL Page 95 A ll rf==s 45% PUBLIC CONSULI INC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report -and she is the one who signed the note. H2017 T1007 Pass Fail Pass Pass Fail Pass NA NA NA Unable to interpret progress note and support intervention. Unable to interpret progress note and support units billed. Treatment Plan does not include speci?c interventions that will promote Basic Living Skills Development. Skills Training,'Therapeutic Socialization. A separate PSR plan is not documented. T1007 T1007 T1007 T1007 T1024 Fail NA NA NA Pass NA NA NA The discharge plan is not quanti?able without time limits for treatment. NA Fa? Fail NA NA NA NA NA Pass Pass NA NA NA NA NA NA Unable to document that an update was appropriate on this date see comment below. Electronic signature does not contain capy of signature of consumer. Supervisor signed 5126111. Dates do not support supervision occurred. Treatment plan header contains date of 612012011, signatures are dated 9115/2011. Goals are dated 912112009. Unable to support that an update took place. Electronic signature does not contain copy of consumer handwritten signature. NA Fall NA NA Pass NA NA NA Treatment plan dated 51312011. Goals dated 5181200710 512011. 512011 goals lows on Depressive Assess does not support active Major Depression. The discharge plan lacks dates. not speci?c. Treatment plan shows target dates of 811412011 for all goals including those set in 51812007. NA Fail NA NA Pass NA NA The duration was not documented in quanti?able terms. Pass Fail NA Fail NA Pass NA NA Treatment plan does not document resource management services will be provided. Lacking mentiin attendance reports. transition plan. CONFIDENTIAL Page 96 0 All ITIW PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report T1024 Pass Fail Fail NA Pass NA NA Treatme 1 plan does not document resource management Treatmellt plan update dates 413012012, all goals are dated 1II31120 1 with no updates on progress toward reaching goals. Missing 9 attendance reports, transition plan. The client's -complianoe is addressed in this dos unplanned group progress report. CONFIDENTIAL Page 97 A A State of New Mexico Human Services Department Behavioral Health Provider Audits CONSUI IINC. (.llOLll' Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ If2009 1/3 [/2013 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Counseling Associates Inc. Final Report Sample Size ISO Total Paid for Sample $10,818 Sampling Frame Size 1 17,76] Number of Sample Claims with Overpayments 53 Tentative Overpayment Using Lower Bound of the 90% Con?dence Interval $2,757,585 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 98 0 Age PUBLIC CONSULI INC. GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report during calendar year 20l2. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Proc Program of Cases Claims 8 Claims Claims Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed H2015 Ho? 5 282 20,148 282 20,148 100.0% H2017 Psy?h?5??ial Rehabilitation Multi- H2033 Systematic 5 455 104,805 392 87,828 86.2% Therapy Grand Total 15 1,702 255,543 1,439 210,548 84.6% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker Therapist Nurse BMS MST Peer Support Rehabilitation Unknown/Other Total Sta?' Reviewed CONFIDENTIAL Page 99 5% A State of New Mexico ll Human Services Department Behavioral Health Provider Audits PUBLIC Sg?suu INC. Final Report IT Billing Systems Audit System Overview Counseling Associates utilizes the Anasazi System for most of its medical records and billing. The system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really super?cial, such as: The way menus are customized to be displayed per the user roles, 0 How user roles are de?ned, 0 The customization and scheduling of reports and 0 When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most agencies in the Rio Grande system stay one to three updates behind the most recent. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. The software is actually installed on the Counseling Associates Microsoft Window Network but it is primarily accessed through the Citrix system, which allows all administrative and clinical staff to access the system from any computer. Anasazi would not allow Counseling Associates (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. Bill Procsing After services are provided to the client, the clinician updates the ?le with notes and the time and date of encounter. The Anasazi so?ware processes this information and calculates the number of units that the service should be billed for, and what code should be assigned to the service, using the service provided and start and stop times of the service. The service is processed by the Anasazi system and transformed into an 837 billing format, which is uploaded using the Optum Netwerkes ACH system. IT Contacts CONFIDENTIAL Page 100 as State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC gfoill?uu Final Report Application Controls - System Administration and Segregation of Duties Therrare two systems that users access: the?Microsoft Windows Network~and the Anasazi System. The Anasazi system is accessible both through the Windows network and through any computer that is connected to the internet through the Citrix system. For that reason, PCG will only discuss Anasazi access in this report; the Windows network users are held in audit documentation collected by PCG for any required future reference. User Roles System Admin Group: Can add users and con?gure data sheets for health plans and services. 1. 0 Administrative Group; Can con?gure data sheets for health plans and services. Medical Records and Intake Groups: Records Clerks and Intake Staff have administrative levels of access to records; primarily administrative and demographic records and read only for clinical information. Clinical Group: All clinicians who bill are in the Clinical Group. They can enter clinical service provision to the system. 1. 2. Rio Grande Sugrvisors Group: Staff from Rio Grande Behavioral Health Services have a supervisory user role per their management services agreement with Counseling Associates. Auditors Group: No staff at Counseling Associates currently have the Auditor Role, but they have established Auditor accounts should outside auditors need access. 0 CONFIDENTIAL Page 10l 5% A fp?K" State of New Mexico Human Services Department Behavioral Health Provider Audits (.llOLll' Final Report IT and Weaknesses Counseling Associates? Anasazi applications are available from any computer connected to the internet via Citrix, which make for ease of use from any computer and maintains a uniformly enforced security policy. Users do not share login accounts. The Anasazi software offers sequestration of clinical information so that users? roles determine the kind of information each user may have access to on a per client basis. For example, a front of?ce clerk may have access to certain demographic information, but Each clinician enters his/her own billing information. Each clinician does not know what codes are used for billing the service provided, he/she only knows what service is being provided. In cases of time duration-based billing units, Anasazi software calculates units billed based on start and end times recorded by the clinician. Anasazi software allows for members of a group therapy session to arrive and leave at different times, allowing for more accurate tracking group services, and therefore billing. Weaknesses: The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. The 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 can make any changes to billing with no audit trail. Training is done mostly on an ad hac basis. Recommendations Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. Develop formalized training system for all users who create charge entry and billing. CONFIDENTIAL Page 102 PUBLIC .l INC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Counseling (CALLECG began_by locating CAlis legaLentity, its of?cers, and_organizers. PCG also reviewed initial founding and leadership information on CAI. PCG located and reviewed CAl?s audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches 0 on the organization or related individuals. Key Staff First Name Last Name Position Marti Everitt Exec Director Wayelene Haley Fiscal Director Bari Bellicini President Kathleen Wells VP Cory Woodbury Treasurer Sally Gonzales Secretary Armando Lopez Director Howard Hicks Director Paula Marshal Director Henry Dickson Director Seyed Nazirpour-Caloor Nurse Practitioner Financial Relationships CONFIDENTIAL Page 103 A A State of New Mexico I I Human Services Department 0 Behavioral Health Provider Audits PUBLIC E?gtlguu INC. Final Report Counseling Associates contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources functions. The organization paid $l97,000 in 20091 for these services. Rio Grande is a provider-sponsored network and each organization?s board members serve as rotating members of the board. While Rio Grande Behavioral Health Services receives fees from its members, has also distributed various grants back to its members. In addition, CAI contracts with Rio Grande Management, LLC (RGM) paying $182,000 (2009) for management services. These include legal services and the provision of executive management. Providence Service Corporation fully owns RGM. Providence is a large, for pro?t, national corporation providing government sponsored social services directly or indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. CAl?s Executive Director, Martha Everitt, is an employee of Providence Service Corporation and was paid $102,000 from this related organization in 2010. Summary of Findings and Recommendations Findings Recommendutiuns In disclaimers, Rio Grande/Providence Full disclosure of executive effort, member organizations state that management compensation, and bene?ts should be staff may have other re5ponsibilities to revealed for this organization and for its iProvidence. These arrangements make it services to Providence Service Corporation. unclear if the executives charged by: Providence are part or full time for this organization. Moreover, without full disclosure, it is dif?cult to determine if the salaries or fees are reasonable. On the surface, the arrangements and amounts paid appear reasonable, but this weak and abnormal public disclosure and may have the effect of masking excessive compensation or Most recent year for which representative payments for both behavioral health and management services were reported. 0 CONFIDENTIAL Page l04 as 41%: AA, A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report (.nouv bene?ts. In addition, these arrangements circumvent federal disclosure requirements for charities ?ling Form 990 and make it difficult for the public to benchmark charitable organizations. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2011. 2010. 2009 Provider Organizational Chart Current Form 990 (Nonpro?t ?ling) 2012, 2011, 2010 Contracts Balance Sheet 2009 2010 Asset: Cash cash equivalents 770,696.00 5 412,334.00 Contracts receivable and other, net of allowance of $53,746 (2009); $92,726 (2010) 307,498.00 289,866.00 Prepaid expenses 31,536.00 23,289.00 Leasehold improvements 8 165,642.00 8 165,642.00 Computer equipment software 331,258.00 331,258.00 Of?ce equipment 133,145.00 138,486.00 Vehicles 3 103,862.00 103,862.00 Less accumulated depreciation (604,632.00) (663,782.00) Total Assets 1,239,005.00 800,955.00 Liabilities Accounts Payable 55,142.00 8 $2,763.00 Accrued Expenses 8 559,1 15.00 577,376.00 Contract revenue not yet earned 8 1,950.00 8 4,450.00 CONFIDENTIAL Page 105 2% um I State of New Mexico Human Services Department Behavioral Health Provider Audits CONSLII IING Final Report ouour Due to others 44,292.00 5,133.00 Deferred rents 75,327.00 63,494.00 Total Liabilities 735,826.00 8 703,2 I 6.00 Net Assets 503,179.00 8 97,739.00 Total Liabilities and Net Assets 5 1,239 005.00 800,955.00 Income Statement 2009 2010 2011 Revenue Grants Contract 8 3,854,276.00 3,543,018.00 Contributions fees 8 3,770.00 - Interest income 3 5,590.00 549.00 Total Revenues and Support .8 3,863,636.00 3,543,567.00 5 - Expenses Program Expenses 3,589,294.00 3,551,216.00 Admin Expenses 449,522.00 376,880.00 Fundraising 24,606.00 20,912.00 Total Expenses 4,063,422.00 3,949,008.00 - Change in Net Assets 8 (199,786.00) 8 (405,441.00) 8 - Net Assets, beginning of year 8 702,965.00 8 503,179.00 897,738.00 Net Assets, end of year 5 503,179.00 8 97,738.00 $97,738.00 CONFIDENTIAL Page 106 Families and Youth Inc. Clinical Narrative lT Narrative Enterprise Narrative 4% ll PUBLIC CONSULTING GROUP if?K?: State of New Mexico 0 I Human Services Department Behavioral Health Provider Audits PUBLIC Sign?!? INC Final Report FAMILIES AND YOUTH, INC. BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit mm March 6-33, "sis Main Point of Contact at Facility Extrapolated Date of Service Overpayments $565,309 Actual Longitudinal Overpayments $291,436 Total Overpayments $856,745 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal! Compliance Rate Provider Scorecard Signi?cant A an- This scorecard result translates to the following Risk Tier: Tl?pm of Findings State A diam 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management 6 to improve processes. CONFIDENTIAL Page 122 I?Ulil IC (.ONSLII FINC State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Provider Overview Families and Youth Inc provides behavioral health services in southwest New Mexico and has locations across the region. Within these locations, Families and Youth lnc, delivers behavioral health services including; AmeriCorps program services, behavioral management services, child and adult care food program, consumer bene?ts and eligibility, family programs, substance residential services, treatment foster care, youth employment programs and community correction program services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 5 Claims Paid FY12 Claims Paid Audit Period BHSD MW 42 CYFD 426,290 1,772,589 Medicaid FFS 206,436 1,016,794 Medicaid MCO 5,252,161 20,456,244 NMCD 0 0 Other 133,827 778,187 Grand Total 6,018,714 24,023,856 Audit Team Observations 0 Upon arrival, PCG was immediately escorted to the of?ce of - named?, as the primary point of contact for PCG and also introduced the PCG team to? - Other FYI clinical staff, including were introduced and charged with responding to PCG questions throughout the course of the audit. 0 Hard copy case ?les were provided to PCG almost immediately. 0 From time to time it was necessary to ask for certain documents that were not included in the case ?les; these were provided CONFIDENTIAL Page 123 A ll as PUBLIC CONSULI INC GROUP 0 All case ?les followed a consistent organizational format. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 Documents such as training records and credentials were retrieved and delivered separately. 0 Clinical Reviewers noted the following general ?ndings: 0 Random Date of Service Claim Review Safety Assessments were not completed or updated for consumers who were assessed to "have current or past suicidaT ideations I, homicidai ideations (HI), sel?i?a?? or domestic violence issues. Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessment was many years prior to the dates of service under review. Treatment plans were missing, not up to date, and/or not individualized per consumer. Discharge plans were not always complete or individualized to the consumer. Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. PCG reviewed one hundred and forty-eight (148) 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 random audit sample and the resulting ?ndings: Procedure . 9f 3 ?flue Claims ?The Claims Program Description Clalms Claims .led Claims Filed Reviewed Reviewed Failed I 9080] Diagnostic 9 983 0 0.0% Evaluation 90804 Outpatient?4060 minutes 6 258 0 0 0.0% 90806 Outpatient?45-50 minutes 17 1 102 0 0 0.0% 90846 amin Therapy 3 323 0 0 0.0% 90847 Family Therapy 18 1376 0 0 0.0% 90853 Group Therapy 5 121 0 0 0.0% 90862 Medication Management 15 1117 0 0 0.0% CONFIDENTIAL Page 124 2% A A State of New Mexico Human Services Department Behavioral Health Provider Audits iiNG Final Report H0015 Intensive Outpatient Program 4 249 0 0 0.0% H0031 Mental Health Assessment 404 0 0.0% H0041 Foster Care(Shelter) 7 3299 0 0 0.0% H2010 RN Medication Monitoring 1 34 0 0 0.0% mm 3' 294- 0 1} 0.0% H2014 Behavior Management Services I 866 10 804 90.9% H2015 HO, 12 1039 974 91.7% H2033 Multi-Systematic Therapy 15 3245 0 0 0.0% 85145 Treatment Foster Care ll 19248 0 0 0.0% T1005 Respite Services ID 734 0 0 0.0% Behavioral Health Treatment T1007 Plan Update 3 331 1 111 33.3% Grand Total 22 1,889 14.9% Specific Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: 148 35,023 CONFIDENTIAL Page 125 a State of New Mexico A I i I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP P5 ch.l . . . Consent Progress Billing Staffing Pharma Other Comments Notes Forms Assessment Treatment Service {Screening Plan Delivery .- plan was not submittedIMissing document. Documentation is not clear on what interventions were provided. Documentation does not support the medical necessity for units b?iedlA on! plan was not submittedIMissing document. not on staff list provided/missing creden issing document. Progress hote documents BMS worker attending team meeting H2014 Pass Pass NA Fail NA Pass NA NA NA with school, case mrkers and step mom to discuss suspension of oonsunier from school. No projected date of discharge located?am is H2014 Pass Fail NA Pass NA Fail NA NA NA not on that staff list providedlmissing credentials/missing document}; No docurrlentation of speci?c interventions related to goals and objectivesl 4 hours at a client's home is questionable and the H2014 Pass Pass NA Fail NA Fail NA NA NA note docul'nents this was a face to face at the client's home. it it was also at the school it was not documented as such. not on the]stafl roster for FYI. No dischath plan intervention of EMS services is not document . BMS intervention was not documented. - not included on stall roster. A treatment plan was not merited, there is a 30 day interim treatment plan but it does no include EMS. Out of home placement risk is not documented? here is no iat eval submittedlMissing H2014 Fari Fail NA Fail NA Fall NA NA NA documen . this was a day out for an activity-no interventions regarding intorcemenllredirection.time cuts or verbal de- escalation:were noted or addressed. ?5 not on H2014 Pass Fail NA Fail NA Fail NA NA NA H2014 Fail Fail NA Fail NA Pass NA NA NA 1* CONFIDENTIAL Page 126 A i ll PUBLIC CONSULI INC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report if?? the staff ster, she signed the progress note as did who is noton roster eitherIMissing creden?atsfMissing documents. A 5 axis diagnosis Is not documentedIMissing documentii. A full screening is not doctimentis. None noted. - and are not on the staff list provided/Missing credentialsIMissing documents. No documentation of treatment planfmissing document. There is only a stall time but no end time on this PN. Cannot read the . . . signature bf the staff member. ?and - "2?\Mnters n?t located on staff list provided. Missing staff credentials. No documentation of treatment planlmissing document; The psyotlosociai assess is dated as 41112012 -AFTER this H2014 Fail Pass NA Pass NA Pass NA NA NA DOS. Assessment is dated 4I11l2012, after this 008. Assess tis dated 4i11l2012. after this DOS. Progress Billing Commenzs Notes Recipient Assessment Treatment Service DOS [Screening Plan Delivery Missing - - - mentsl no or oval in clients documents. There is only a functional assessment. There is no RXP to go with this DOS-the treatment plan is dated 11/2512011 and this dos There is noRXPtogcwith this DOS- i-f2014 Fail Fail NA Fail NA Fail NA NA NA the treatment plan is dated 1112512011 and this DOS ls 8130I201 . ?fs not on the provider list! missing credentia . Missing documents! no or eval in cli to documents. There is only a functional assessment. There is rlo risk assessment. none noted. . Trealrnerit plan is not documentedIMissing documents. Treatment H2014 3 Pass Fail NA Pass NA Pass NA NA NA plan is documents. Treatment pian is not ?r dowmeniedlMissing dowments. Treatment plan is not CONFIDENTIAL Page 127 ?rm ll PUBLIC CONSULTING 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report documents. H2015 Pass Pass Pass Fai NA Fail NA NA NA Not noted. Review of start roster resulted in finding that .did not meet requirements of a CSWIm?tssing documents. H2015 Pass Fail Pass Fail Pass NA NA Not noted. Formal treatment plan was not submitted. The Interim 30 day plan with non speci?c goals and no discharge plan was the only 'l?P submitted. H2015 Pass Fail Fail Fail Fail NA NA NA A progress note was not submitted. Time spent was not documeriled. Review of staff roster depicts ?as not quali?ed; H2015 Fail Pass Fail Fail NA Fail NA NA NA There was no contact with the client orthe family in this PN.- this was a phpne call between the CSW and another individual regarding the ctient. There was no contact with the client or the family in this PM. Phone call was not to or from the client's family member-the phone call was between the CSW staff and another individual regarding the client? not on the staff ?st of protridersIMissing documen . vrew of staff roster depicts H2015 Pass Pass Pass Pass Fall NA NA NA credentidshnissing documents. H2015 Fail Pass Pass Fail Fail NA NA NA Assessment is dated two months after this CCSS service date. None netted-is depicted on the staff roster review as not meeti'tg qua??cationslMissing document-s depicted ion the staff roster review as not meeting quali?cationslMissing document. status exam dated 712912010-ptior to this 008. H2015 Fail Pass Fail Fait Fail NA NA NA Progress'note documents meeting with school staff, consumer was not present Unable to document medical necessity of units bmed traded on progress note?m CONFIDENTIAL Page 128 A PUBLIC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 Pass Pass NA Fail NA NA NA review oil staff roster as not meeting quali?cations. -'iis depicted on review of staff roster as not meeting qualifications?s depicted on review of staff roster asinot meeting quali?cations. No documentation of Substanqe Abuse assessment. There is a crisis plan tor 11/1 8 - but no updated one for 2009. Not add ssed on this PN. Review of staff roster depicted not meeting quali?cations. H2015 Fail Fail Fail Fail NA Fail NA NA NA No osocial or eval submittstan documents. No docu tation of treatment planIMissing documents. Limited informatipn on the PM by practitioner- document relates client's mother is} requesting help other than the current services as the mother dbes not feel her daughter is getting the help that she needs. Quali?cations review for ?resuited in depicti her as not meeting requirements for a CSWImissing credenti islmissing documents. H2015 . Fail Pass Pass Fail NA Fail NA NA NA None noted or addressed-ETd-arT H2015 l. Fail Fail Fail Fail NA Fail NA NA NA not on th staff list provided. Quali?cations were not submitted for Quali?cations were not submitted for-? Docum tation was not submitted for review. None of the foilowingl, were submitted: treatment plan, Assessment. Diagnosis, progress note. Unabte to support that services were rende . Quali?cations were not submitted T1007 - NA Fail NA NA NA Fail NA NA as depicted as not meeting required quali?ca one during the stall roster review. Note was CONFIDENTIAL Page 129 ate State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report GROUP Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/1/2009 1/3 l/2013 Sample Size: Sample size is 148 claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Families and Youth Inc. Sample Size 148 Total Paid for Sample $35,023 Sampling Frame Size 71,222 Number of Sample Claims with Overpayments 22 Tentative Overpayment Using Lower Bound of the 90% $565,309 Con?dence Interval Longitudinal File Review PCG selected between one and five of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 130 Agra 4% State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report CONSUH INC. during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: I Proc Program of Cas Claims 3 Claims Claims Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed .H2033 Systematic 5 269 73,192 54 15,393 20.1% Therapy 35145 new? 5 66 231,455 65 276,043 98.5% Foster Care Grand Total 10 335 354,647 119 291,436 35.5% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker TLP Therapist 25 Milieu Counselor 2 2 Unknown/Other 3 Total Staff Reviewed 44 CONFIDENTIAL Page 13 I 0 as? State of New Mexico Human Services Department Behavioral Health Provider Audits I on PUBLIC INC Final Report (I I Billing Systems Audit System Overview Families and Youth, Inc. (FYI) utilizes the Anasazi System for most of its medical records and billing. The system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really super?cial, such as: 0 The way menus are customized to be displayed per the user roles, 0 How user roles are de?ned, 0 The customization and scheduling of reports and 0 When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most agencies in the Rio Grande system stay one to three behind the most recent. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. The software is actually installed on the Microsoft Window Network but it is primarily accessed through the Citrix system, which allows all administrative and clinical staff to access the system from any computer that is connected to the intemet. Anasazi would not allow FYI (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. Bill Processing After services are provided to the client, the clinician updates the file with notes and the time and date of encounter. The Anasazi software processes this information and calculates the number of units that the service should be billed for, and what code should be assigned to the service, using the service provided and start and stop times of the service. The service is processed by the Anasazi system and transformed into an 837 billing format, which is uploaded using the Optum Netwerkes ACH system. IT Contacts 0 CONFIDENTIAL Page 132 as A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSLII ?Nb Final Report Application Controls - System Administration and Segregation of Duties There are two systems that users access: the Microsoft Windows Network and??ie Anasazi System. The Anasazi system is accessible both through the Windows network and through any computer that is connected to the internet through the Citrix system. For that reason, PCG will only discuss Anasazi access in this report; the Windows network users are held in audit documentation collected by PCG for any required future reference. User Roles System Admin Group: Can add users and con?gure data sheets for health plans and services. Medical Records and Intake Groups: Records Clerks and Intake Staff have appropriate administrative levels of access to records; primarily administrative and demographic records and read only for clinical information. Clinical Group: All clinicians who bill are in the Clinical Group. They can enter clinical service provision to the system. Rio Grande Supervisors Group: Staff from Rio Grande Behavioral Health Services have a supervisory user role per their management services agreement with Auditors Group: No staff at FYI currently have the Auditor Role, but they have established Auditor accounts should outside auditors need access. IT and Weaknesses Anasazi applications are available from any computer connected to the intemet via Citrix, which make for ease of use from any computer and maintains a uniformly enforced security policy. 0 Users do not share login accounts. CONFIDENTIAL Page 133 A f?s a State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. amour Final Report The Anasazi software offers sequestration of clinical information so that users? roles determine the kind of information each user may have access to on a per client basis. For example, a front of?ce clerk may have access to certain demographic information, but Each clinician enters his/her own billing information. Each clinician does not know what codes are used for billing the service provided, he/she only knows what service is being provided. cases?6f time duration-based?billing units, Anasazi software calculates units billed based on start and end times recorded by the clinician. Anasazi software allows for members of a group therapy session to arrive and leave at different times, allowing for more accurate tracking group services, and therefore billing. Weaknesses: The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. The 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 can make any changes to billing with no audit trail. Training is done mostly on an ad hoc basis. Recommendations Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. Develop formalized training system for all users who create charge entry and billing. CONFIDENTIAL Page 134 9% A State of New Mexico Human Services Department Behavioral Health Provider Audits CONSULIING Final Report enour Enterprise Audit Provider Specific Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Families and also reviewed initial founding and leadership information on FYI. PCG located and reviewed FYl?s audited ?nancial statements and tax data. PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches on the organization or related individuals. A separate entity - Resources for Children and Youth was founded for the bene?t of FYI. Both organizations were reviewed simultaneously. Key Staff First Name Last Name Position Felipe Peralta Chairman Reese Carson Vice Chairman Dr Ivan Alexandre De La Rosa Sec/Treasurer Lisa Dalton Board Member Dr John Patton Board Member Joe Martinez Board Member Bill Stickles Board Member Bill Stickles Board Member Jeannine Apodaca Board Member Karen Wootton Board Member Maria Gutierrez Board Member CONFIDENTIAL Page 135 A A State of New Mexico ll I Human Services Department Behavioral Health Provider Audits PUBLIC CONSUI IINC. Final Report GROUP Natasha Fulbright Board Member Omar Montoya Board Member Barbara Myers Board Member Barry Irons Jose Frietze Exec Director/CEO Mickey Curtis Clinical Director 'Renee Curtis CEO Sharon Tariol Nurse Brian Hodges Program Director Madelon Winters Program Director Dexter Sandoval CFO Financial Relationships Families and Youth, Inc. contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources. The organization pays approximately $475,000 annually (2009?) for these services. Rio Grande is a provider sponsored network and each organization?s board members serve as rotating members of the board. While Rio Grande Behavioral Health Services receives fees from its members, has also distributed various grants back to its members. In addition, Families and Youth, Inc. contracts with Rio Grande Management, LLC (RGM) paying approximately $572,000 (2009) for management services. These include legal services and the provision of executive management. Providence Service Corporation fully owns Rio Grande Management Services. Providence is a large, for pro?t, national corporation providing government sponsored social services directly or Indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. The Executive Director of this organization is an employee of Providence Service Corporation. In 2011, the Executive Director, Jose Frietze, was paid approximately $212,000, and Rio Grande CFO Dexter Sandoval was paid 15 hours per week from this related organization. Mr. Sandoval is also the CFO of Most recent year for which representative payments for both behavioral health and management services were reported. CONFIDENTIAL Page 136 A r?N State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits PUBLIC CONSULI Final Report GROUP Summary of Findings and Recommendations Findings In disclaimers, Rio Grandc/Providence Full disclosure of executive effort, member organizations state that management compensation and bene?ts should be revealed staff may have other to. foe?thismganization?anmfonjmm. Providence. These arrangements make it Providence Service Corporation. unclear if the executives charged by Providence are part or full time for this organization. Moreover, without full disclosure, it is dif?cult to determine if the salaries or fees are reasonable. On the surface, the arrangements and amounts paid appear reasonable, but this weak and abnormal public disclosure may have the effect of masking excessive compensation or bene?ts. In addition, these arrangements circumvent 0 federal disclosure requirements for charities ?ling Form 990 and make it dif?cult for the public to benchmark charitable organizations. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2011, 2010. 2009 Provider Organizational Chart Current Form 990 (Nonpro?t ?ling) 2011, 2010, 2009 Contracts CONFIDENTIAL Page 137 as 25m: A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI ENG Final Report GROUP Balance Sheet 2009 2010 Asset: Cash cash equivalents 2,493,154.00 2,476,185.00 Investments - certi?cate of deposits 552,419.00 469,033.00 Accounts grants receivable, less allowance for doubtful accounts of $72,327; $195,139 (2010) 1,385,468.00 1,016,234.00 Prepaid expenses 53,196.00 46,135.00 Interest receivable from af?liate 14,139.00 5 1,75 I .00 Storage building 3 26,584.00 26,584.00 Furniture equipment 820,542.00 823,729.00 Improvements 806,592.00 806,592.00 Vehicles 219,109.00 285,184.00 Less accumulated depreciation (1,325,019.00) (1,433,627.00) Note receivable from af?liate, long-term portion 649,612.00 174,612.00 Deposits 1,200.00 1,200.00 Total Assets 5,696,996.00 4,693,612.00 Liabilities Accounts Payable 1,585,024.00 142,310.00 Deferred revenues 153,633.00 236,787.00 Accrued liabilities 97,457.00 93,055.00 Accrued salaries 161,453.00 161,476.00 Accrued compensated absences 149,435.00 5 362,408.00 Due to Of?cer 45,1 17.00 - Total Liabilities 2,192,119.00 996,036.00 Net Assets 3,504,877.00 3,697,576.00 Total Liabilities and Net Assets 5,696,996.00 4,693,612.00 CONFIDENTIAL Page 138 a?e- State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits I?Lllil IC CONSUI inal Report (noun Income Statement 2009 20I0 20? Revenue Federal Funds 8 5,281,613.00 4,937.3 87.00 State Funds 8 1,928,983.00 1,665,465.00 Local Funds 5 2,107,156.00 2,862,829.00 Service fees - Medicaid 5,261,360.00 5,182,002.00 Contributions 36,419.00 3 39.5 66.00 Interest income 3 41,454.00 39,410.00 Unrealized gain on investment 10,973.00 (49,491.00) Miscellaneous 3 266.00 - Total Revenues and Support 3 14.668.224.00 3 14.677.168.00 5 - Expenses Program Expenses 13.973.000.00 8 14.169.251.00 Admin Expenses 197,346.00 3 215,926.00 Fundraising 34,344.00 5 99,292.00 0 Total Expenses 14.254.690.00 3 14.484.469.00 5 - Change in Net Assets 5 413,534.00 192,699.00 5 - Net Assets, beginning of year 8 3,091,343.00 3,504,877.00 3,697,576.00 Net Assets. end of year 3,504,877.00 3,697,576.00 3,697,576.00 CONFIDENTIAL Page 139 Hogares Inc. Clinical Narrative iT Narrative Enterprise Narrative ?g PUBLIC CONSULI ENC GROUP State of New Mexico II Human Services Department Behavioral Health Provider Audits PUBLIC CONSLILI INC. Final Report (moun- HOGARES, INC. BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit mm on I 1 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $3,629,976 Actual Longitudinal Overpayments $103,063 Total Overpayments $3,733,039 Scorecard results are as follows: Longitudinal Rate Random Sample Compliance Rate Provider Scorecard Signi?cant A M- This scorecard result translates to the following Risk Tier: Trims of Findings- State Minus 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. I Potentially embed clinical management to improve processes. CONFIDENTIAL Page 140 52%? A State of New Mexico I I Human Services Department 0 Behavioral Health Provider Audits Sgtlus'w 1th . Final Report Provider Overview Hogares Inc provides behavioral health services in Bernalillo, Cibola, Sandoval, Torrance and Valencia counties. Within these locations, Hogares delivers behavioral health services including access and intake services, therapeutic outpatient intervention services, comprehensive community-supporrservices, treatment foster transition living services and respite care services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer Claims Paid FY12 3 Claims Paid Audit Period BHSD 37,425 40,714 CYFD 352,441 951,461 Medicaid FFS 775,304 2,656,520 Medicaid MCO 8,257,434 27,089,835 NMCD 0 0 Other 0 0 Grand Total 9,422,603 30,738,530 Audit Team Observations I On Wednesday, February 27th, PCG conducted an entrance conference upon arriving onsite. was offsite so? - was designated to serve as the team?s point of contact. Michelle Comeaux explained the reason why PCG was there, what we needed to review, and the anticipated sequence of events, in addition to answering any questions. - PCG received their first case ?le within 15 minutes and reviewed the ?le with- - to ensure PCG understood the documentation in the records. 0 Hogares staff pulled all the requested consumer and staff documentation. All requested consumer documents were consistently being brought to PCG staff to be scanned. Some of the ?les were electronic; however, Hogares staff printed hard copies for PCG to scan. 0 CONFIDENTIAL Page 14] AAT 2% CONSLILI INC. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 The majority of the consumer and staff documents were provided over ten days. A few of the requested ?les were provided later because they had to be retrieved from storage. 0 On Wednesday, February IT Lead, Mike Dieter, met with to review their billing and clinical systems, including inputs, outputs and audit trails. 0 Hogares staff was always prompt in responding to audit team requests for clari?cation or addi?onaLinfonnation. 0 Clinical Reviewers noted the following general ?ndings: 0 Random Date of Service Claim Review Comprehensive Clinical Assessments did not always support medical necessity for the billed service or the provided assessments were incomplete of critical information for the date of service under review. Treatment plans were missing, not up to date, and/or not individualized per consumer. Submitted treatment plans did not always cover the dates of service under review. Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. PCG reviewed one hundred and forty seven (I47) 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 random audit sample and the resulting ?ndings: Procedure Program Description of Value Claims 8 Value Claims Code Claims Claims Failed Claims Failed Reviewed Reviewed Failed 9080] Diagnostic 5 489 0 0 0.0% Evaluation 90804 Outpatient?20-30 minutes I 43 0 0 0.0% 90806 Outpatient?4560 minutes 13 872 0 0 0.0% 90847 Family Therapy 13 990 0 0 0.0% 90853 Group Therapy 3 61 0 0.0% 90862 Medication Management 2 I46 0 0 0.0% [10019 Transitional Living Services to 1590 0 0 0.0% CONFIDENTIAL Page 142 State of New Mexico I Human Services Department Behavioral Health Provider Audits IL CONSLII ilN(. Final Report onoul' H2014 Behavior Management Services I9 I932 9 1203 47.4% H2015 HO, HN, 33 232] 23 1699 69.7% Q3014 Telehealth Facility FeelCode 5 112 0 0 0.0% 85145 Treatment Foster Care 33 5234 0 0 0.0% 111005 Respite-Services 10 635 0 0 010% Grand 147 14,474 32 2,902 21.8% Total Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 143 ?n A Human Services Department I I Behavioral Health Provider Audits PUBLIC INC Final Report State of New Mexico . Consent Progress Billing Staffing Pharma Other Comments Forms Notes Proc Recipient Assessment Treatment Service Code DOS lScreening Plan Delivery No docu entation of support for EMS services. Comp Assessment dated 4I30I12. Recommendation for C083 services. 0088 Recovery &: Resiliency Plan dated 6120/1 H2014 Fail Fall NA Fail NA Pass NA NA NA only. No BMS Tx Plan. only CCSS interventions. Documentation does not support 16 units. No documentation of EMS services nor recommendation. Recommendation for CCSS services only. No BMS Tlelan. No BMS Tx Plan. Reviewer examined the Evaluation and Enhanced Assessrdent which did not list behaviors that could potentially lead member to an out of home placement NMAC 8.3223. Documentation does not support units billed NMAC 3.3223. The quali?edistatf identi?ed as rendering the service was Hogares Inc. H2014 Fail Pass NA Fail NA Fail NA NA NA NMAC8322.3. Tx plan rarely includes parents/famin and are focused towards the school environment. NMAC 8322.3. The agency is addressing AutismlPervasive Developmental Disorder and the diagnosis is not listed on the Enhanced assessment or evaluation as one of the member's diagnosis. NMAC 8.32.2.2? No documentation to support the billed service of EMS. H2014 Pass Fail NA Fail NA Fail NA NA NA Practitioner not listed to determine quali?cations. Documentation is related to TFC. Documentation is related to TFC. Units rig biiled are 23. Time listed is 0955 to 3:40pm Each unit . is equal 15 minutes of time. ?is the provider H2014 Pass Pass listed. ere is a -on the provider list however there is no last no added. Names are listed ?3nd_' H2014 Pass Fail NA Pass NA Pass NA NA NA _roviders are not round on pmviderilist. CONFIDENTIAL Page 144 I PUBLIC. CONSULI ll\C GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2014 Pass Pass Fail NA Pass this DOS 5/20111 are listed two times starting with 0845 end time of 11:45 then 1600 start time with an end time of 1700. Units billed are for 25. Each 15 minute interval is equal to 1 unit. H2014 Pass Pass NA Pass NA Pass NA NA Fail No dommentation of progress or lack of. H2014 Pass Pass Pass NA Pass NA NA Fail BMS Note appeals to be more a list of done with consumer. rather than a clinical look at progress and the activities relation to goals. H2014 Pass Pass NA Fail NA Fail NA NA NA No interventions documented for billed date of 11193012. CONFIDENTIAL Page 145 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report Recipient Assessment Treatment Service Consent Progress Billing Staffing Piiarma Other Comments DOS [Screening Plan Delivery Forms Notes No documentation of client's risk assessment. highlighted in red on provider list is highlighted in Red on provider list. CSW to discuss with JPPO team close of client ?le as client has not it found. CSW also discussed with JPPO team that if client is rid how services tor Comprehensive Community support be reiterated. CSW went to meet with JPPO team at JPPO . Client is missing and CSW is discussing with them H2015 Pass Fail NA Fail NA Fail NA NA NA closing case and it Client should be found how to have services reiterated. highlighted In Red on. provrder list� HN modi?er rs the correct code identi?ed with this service date. is highlighted on provider list. is highlighted on provider list in red. No Treatment Plan ew?denced in the record. mghlighted in red on provider sheet. in regard to H2015 Pass Pass Pass Pass NA Fail NA NA NA record license and experience as wet] as trainings. HN code is the proper code. H2015 Pass Pass Pass Fail NA Pass NA NA NA No documentation of clients risk assessment CODE for H2015HN must identify the Provider not the facility for billing with this code. H2015 Pass Pass Pass Pass NA Fail NA NA NA Do nots?ee _iston provider list. Right Ingdi?er appears on claims data sheet however - is highl hted in red on providers list-s highlighted in red on pl'ovider list-is highlighted in red on provider list. H2015 - Pass Pass Pass Pass NA Fail NA NA NA H2015 Pass Pass Pass Pass NA Fail NA NA NA CONFIDENTIAL Page 146 45% Hill f-K PUBLIC. CONSULI INC ?1 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 H2015 H2015 H2015 H2015 H2015 H2015 H2015 H2015 Pass Pass Pass Fail Fail NA NA NA Pass Pass Pass Fail NA NA Pass NA Fail 5 Pass NA NA NA Pass Pass Pass Fail NA NA No on-going risk assessment during this date of service. Staff does not ineet the minimum quali?cations for CSW. Staff does not meet the minimum quali?cations for CSW. Staff does not meet the minimum quali?cations for CSW. is highlighted in red on providers list.- highlighted in red on providers list. Documentation that 0088 had no contact with parent and parent requested closure. 5 highlighted in red on the provider list. highlighted in red on provider list. Pass Pass Pass NA Fail NA NA NA billed services rendered lay?We? this indivilual listed on provided listtheretore unable to note if quali?ed Staff rendered this service. Fail i Pass Pass Pass Pass Pass Pass Fail NA Pass Pass NA NA NA NA NA NA The Contprehensive assessment dated 13290009 shows an Axis I of Adj. DIO (elementary school to middle school) as the only diagnosis. with a GAF of 79. Yet consumer was recommended to EMS. CCS. Individual and Family therapies. Additiondilv, ?Clients mo. No documentation of risk assessment per progress note. Pass Pass Pass Pass NA Fail NA NA NA Signatures are present however unable to read handwriting and therefore uncertain if quali?ed to render the service requi There is a - listed on provider sheet but new It looksasiftl'ie?rstletteris eitheran SorG butnot. Pass Pass Pass Fall NA Fail NA NA NA Assessrrient of risk for child not mentioned although intervention involved father who was identi?ed as past abuser against child consumer. 11 units for a preparation discussion with father of upcoming court appearance in Family Court. self-care. and CONFIDENTIAL Page 147 as?? PUBLIC GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report behaviors resulting from child consumers mood disorder appears to be quite a long session for a non-clinical session.'Hogares' was entered as rendering practitioner rather than- - who actually met with the consumer. H2015 . Pass Pass Pass Fail NA Pass NA NA NA No documentation of client's risk assessment. H2015 Pass Pass Fail Fail NA Fail NA NA NA Unknown exactly where the service was completed. no documentation. No documentation of clients risk assessment Provider does not have credential to bill at this level, unknown credential. H2015 Pass Fail Pass Fail NA Fail NA NA NA Claim data sheet is billed at 7 units. Date of service 2116112 CCSS Crisis safely Plan states 60 minute service provided on this date. Has no quali?cations listed on provider sheet. - - has no quali?cations listed on provider list. states unknovali or none etc across the board for quali?cations license trainings experience. -as no quali?cations listed on provider list States Unknown or none etc across the board. No Treatment Plan in chart. H2015 Pass Pass Fail Pass Pass NA NA NA No progress note for billed date of service H2015 Pass Pass Fail Fail NA Pass NA NA NA H2015 Pass Pass Pass Pass Fail NA NA NA Documentation of telephone call made about resmirces. Documentation of telephone call made by CSW to ?nd information about resources. 018: Documentation does not support units billed. is not noted on Provider list and provider list she signed the note for this . indicated as rendering practitioner, did not provide the service according the documentation. H2015 Pass Pass Pass Fail Pass NA NA NA No dounnentation. CONFIDENTIAL Page 148 A A A State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits PUBLIC CONSLILI lN?tT . Final Report Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/1/2009 1/3 l/2013 Sample Size: Sample size is 147 claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. 0 Hogares Inc. Sample Size 147 Total Paid for Sample $14,474 Sampling Frame S'ue 271,467 Number of Sample Claims with Overpayments 32 Using Lower Bound of the 90% $3,629,976 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid 0 CONFIDENTIAL Page 149 A A A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC lN(. Final Report during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Proc Program of Cases Claims 5 Claims Claims 56:12: Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed Behavior H2014 Management 5 855 [04,457 579 75,233 67.7% Services H2015 5 321 34,527 252 27,830 78.5% CCSS Grand Total 10 1,176 138,984 831 103,063 70.7% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 35 Therapist 32 Community Support Worker Supervisor 1 BMS 1 Residential, BMS, Respite, Other 55 TFS staff 2 Therapeutic Foster Care Staff 13 Unknown/Other 16 Total Staff Reviewed 159 CONFIDENTIAL Page 150 ??ii A 4% State of New Mexico Human Services Department 0 Behavioral Health Provider Audits IC 331st" llNC. Final Report at Billing Systems Audit System Overview Hogares uses EMR Bear as their Electronic Health Record and Practima as their billing system. They interface?With the Optum NetwerkerACH to submit their billsfor processing and payment. EMR Bear is accessed remotely to allow progress note updates. Practima is used for case tracking and billing. Practima is based on industry-standard Microsoft technology and the database is MS SQL Server, also an industry standard. Emdeon is 3rd party system used to check eligibility. Netwerkes is used for the billing clearinghouse. IT Contacts and Weaknesses 0 Have an EHR system that they use to record and track clinical records 0 All users are trained on the software system. 0 Direct access to software system author,_ for issues or questions. 0 is a strong developer and very knowledgeable about this subject area. Very quali?ed to write software for case tracking and billing process for behavioral related claims. 0 Have a process for backing up the system database. 0 Have strong eligibility checking process, training and system (uses Emdeon). - Have strongly documented intake process for new patients 0 Have strongly documented process for submitting billing claims in batch process on regular basis to avoid duplicate billing. 0 Have strong system reporting capabilities to review payments, population treated and other clinical activity across population cross sections. 0 Have a hard connection between EHR system and billing system. Data entered into the EHR system is uploaded into the billing system on a basis. 0 Have a strong process for adding new employees and deleting employees that have been terminated. CONFIDENTIAL Page I 51 State of New Mexico I I Human Services Department I Behavioral Health Provider Audits PUBLIC gg?suu INC. Final Report 0 System appears to be a strong application for submitting claims correctly with accurate pricing. System does contain reports and open database to corroborate billings with progress notes. Weaknesses: The point of entry to the claims payment system provides the ability to change any billng from what the clinician entered. While this has not been observed, it is a considerable weakness. 0 is the only programmer and is the only person who knows the software system from beginning to end. Hogares has no backup for They are looking at alternatives to -to support their report requests. 0 The process for checking that the data transmitted from the EHR system to the billing system is correct is weak. A ?le from EMR Bear is created and loaded into Practima. There is no report or comparison done to ensure that everything that was taken from EMR Bear was transferred into Practima precisely. Recommendations I Should develop regular process or reports to verify that data moved from to billing system is always correct. 0 Need to ?nd alternate source for supporting system in addition to the only staff member who has the necessary know-how. CONFIDENTIAL Page 152 as A A State of New Mexico I I Human Services Department 0 Behavioral Health Provider Audits PLllilJC CONSLII I INC . Final Report (.nour Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Hogares, lnc. PEG?began by-locating~Hogares? legal entityg?its-of?cers, and organizers. PCG also reviewed initial founding and leadership information on Hogares. PCG located and reviewed Hogares? audited ?nancial statements and tax data. PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor's office. Finally, PCG performed media and court record searches on the organization or related individuals. 0 Audit Observations Hogares is a long standing New Mexico non-pro?t providing services for troubled youths and their families. The organization provides residential and outpatient services, foster care and adoption services as well as transitional living skills. At 6/30/2010, the organization had audit ?ndings related to internal controls; these were resolved at 6/3 0/201 1. Key Staff Bill Herman President Tito Chaves Treasurer Pamela Gooden Secretary Katy Braziel Board member Trey Hammond Board member Herb Hughes Board member Loretta Lopez Board member CONFIDENTIAL Page 153 4% A A State-of New Mexico I I Human Servrces Department Behavioral Health Provider Audits PUBLIC CONSLIH INC. Final Report GROUP Edwin Jr Reyes VP Joan Staveley Board member Rosalie Perea Board member Jeff Peters Board member Nancy Jo Archer CEO Larry Leyva Fiscal Of?cer Nestor Baca Board member Kris Carrillo Board member Matthew Glickman Board member Eric Burgmaier Board member Financial Relationships The organization has a service agreement for child with TeamBuilders Counseling Services. The organization paid Zia Behavioral Health approximately $151,000 in 2010; $148,000 in 2011; and $231,000 in 2012. Zia Behavioral Health is owned by Shannon and Lorraine Freedle, the Chief Executive Of?cer and Chief Clinical Of?cer, respectively, of Teambuilders. Summary of Findings and Recommendations Findings Recommendatinns List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2012. 2011. 2010 Provider Organizational Chart Current Form 990 (Nonpro?t ?ling) 2011, 2010, 2009 Contracts Third party contracts Independent contractor agreements CONFIDENTIAL Page 154 22.2: a A A State of New Mexico 1:1uman Services Pcpartmept Behavnoral Health Prowder Audits I?Ulil IC CONSUI Final Report (.0000 Balance Sheet FY2009 FY2010 FY2011 FY2012 Assets Cash cash equivalents 1,776,055.00 2,334,547.00 15 1,344,205.00 1,528,308.00 Accounts receivable, net 721,921.00 5 749,307.00 8 934,869.00 8 857,617.00 Contribution receivable - 38,700.00 45,000.00 5 54.450.00 Prepaid expenses 8 61,942.00 90,999.00 51,128.00 8 78,667.00 Certi?cate of Deposit . . - Property, furniture equipment, net 8 2,799,486.00 2,692,819.00 3,241,621.00 3,077,937.00 Funds held in trust 8 14,407.00 5 15,789.00 8 17,684.00 5 8,547.00 Total Assets 5 5,373,811.00 5,922,161.00 5,634,507.00 5,605,526.00 Liabilities Accounts Payable 189,067.00 5 204,655.00 5 165,410.00 203,546.00 Deferred revenues 3 1,000.00 8 - 45,435.00 5 10,186.00 Accrued expenses 5 24,718.00 5 1,256,347.00 698,385.00 5 779,221.00 Notes payable, current portion 8 - 127,199.00 5 1,178,879.00 1,104,010.00 Notes payable, less current portion 8 1,557,567.00 5 1,475,976.00 5 862,309.00 783,948.00 Accrued salaries, vacation bene?t 8 455,768.00 5 - - - Medicaid advance payments 5 185,035.00 5 - - - Current maturities of long- term debt 5 112,521.00 - 5 - - Funds held in trust for client 14,407.00 15,789.00 8 17,684.00 8 8,547.00 Total Liabilities 2,540,083.00 5 3,079,966.00 2,968,102.00 2,889,458.00 Net Assets 5 2,833,728.00 2,842,195.00 2,666,405.00 2,716,068.00 Total Liabilities and Net Assets 8 5,373,811.00 5,922,161.00 5,634,507.00 5,605,526.00 CONFIDENTIAL Page 155 ?g A ?g State of New Mexico I 1:1uman Services Pepartment Behavroral Health Provrder Audlts PUBLIC CONSULI Final Report moor Income Statement FY2009 FY2010 FY2011 FY2012 Revenue Contributions - public support 23,513.00 17,731.00 74,938.00 94,138.00 State Funds 742,181.00 1,003,221.00 - Medicaid 7,480,278.00 8,126,370.00 8,859,145.00 8,568,931.00 Private insurance 40,302.00 94,070.00 - Bernalillo County 122,000.00 122.000.00 - City of Alburquerquc 93,925.00 93,988.00 - Other 33,888.00 82,721.00 42,913.00 62,378.00 Interest 10,018.00 24,939.00 9,518.00 14,042.00 Federal funding 28,953.00 27.21 1.00 - Sandoval County 22,845.00 6.871 .00 - Valencia County 13.783.00 9.3 83.00 - Rent 26,302.00 27,348.00 37.913.00 29,854.00 APS Mental Health 73,172.00 5 86,057.00 - Expansion grant funding 5 304,128.00 - - United Way funding 43,999.00 60,000.00 - Other funding 38,305.00 38,127.00 - Grants - - 52,725.00 Contracts - - 994,461.00 5 1,033,916.00 Total Revenues and Support 8 9,097,592.00 9,820,037.00 10.071.613.00 9,803,259.00 Expenses Residential treatment Foster care adoption services Outpatient services Transitional living services 5 2,533,056.00 2,391,823.00 3,236,251.00 294,245.00 2,051,189.00 2,571,153.00 3,509,847.00 589,370.00 Management general 1.378.493.00 1,068,408.00 1,151,694.00 1,080,024.00 Program services (combined) 9,095,709.00 8,673,572.00 Total Expenses 9,833,868.00 9,789,967.00 10.247.403.00 9,753,596.00 Change in Net Assets (unrestricted) (736,276.00) 5 30,070.00 (175,790.00) 49,663.00 Change in Net Assets (temp restricted) (84,933.00) (21,603.00) - - Change in Net Assets (Total) (821,209.00) 8,467.00 (175,790.00) 49,663.00 Net Assets, beginning of year 3,654,937.00 2,833,728.00 2,842,195.00 2,666,405.00 Net Assets, end of year 2,833,728.00 2,842,195.00 2,666,405.00 2,716,068.00 CONFIDENTIAL Page 156 Partners in Wellness LLC. Clinical Narrative IT Narrative Enterprise Narrative ?fi . PUBLIC CONSULTING GROUP A State of New Mexico Human Services Department Behavioral Health Provider Audits PUHIJC ENG Final Report GROUP PARTNERS IN WELLNESS BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review February 27 March 6, 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $57,614 Actual Longitudinal Overpayments $22,736 Total Overpayments $80,350 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate Provider Scorecard Signi?cant 1? im- ?Mum? This scorecard result translates to the following Risk Tier: 3 Signi?cant ?ndings, including 0 Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. CONFIDENTIAL Page 157 A State of New Mexico Human Services Department 0 Behavioral Health Provider Audits PLliil If CONSUI Final Report L-ilOlJl' Potentially embed clinical management to improve processes. 0 Potential change in management. Provider Overview Partners in Wellness is located in the Albuquerque metropolitan area. Within this location, Partners in Wellness delivers behavioral health services including substance abuse treatment services, mental health support services and community support services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 3 Claims Paid FY12 Claims Paid Audit Period BHSD 629,556 1,621,900 CYFD 1 1,420 18,062 Medicaid FPS 17,703 34,334 Medicaid MCO 235,159 356,345 NMCD 71,265 82,544 Other 0 0 Grand Total 965,103 2,113,185 Audit Team Observations I An entrance conference was held with immediately upon the audit team?s arrival onsite. 0 Anasazi ?super user? (backup for their primary IT staff person who is located in Hawaii), walked the team through the clinical records according to name and DOS and explained the format of the records. 0 The majority of documentation was provided electronically via transfer of ?les to a thumb drive that was provided to the audit team. I Clinical ?les were provided in a combination of paper and electronic format due to signed consents that are documented on paper and then moved to an electronic format. 0 CONFIDENTIAL Page 158 PUBLIC INC State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Till - Client signatures on treatment plans were done on a hard copy. Staff didn?t have time to pull the hard copies and noted that at times the electronic signature pad was down and clients couldn?t use it. The team did not have access to records for employees who were originally stationed at the Carlsbad provider site. - Clinical?Reviewers noted the following?general ?ndings: 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were not up to date for the date of service under review. 0 Treatment plans were missing, not up to date, and/or not individualized per consumer. 0 Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and ?fty (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 random audit sample and the resulting ?ndings: TiEr $Value SValue . Program Description Claims Claims Claims Reviewed Reviewed Failed Diagnostic 90791 Evaluation 1 90 0 0 0.0% 90001 ?3mm l2 1224 0 0 0.0% Evaluation 90804 Outpatient?20-30 minutes 2 82 0 0 0.0% 90806 Outpatient?45-50 minutes 14 926 0 0 0.0% 90808 Outpatient?75-80 minutes 2 153 0 0 0.0% 90847 Fernin Therapy 1 78 0 0 0.0% 90853 Group Therapy 33 841 0 0 0.0% 90862 Medication Management 5 361 0 0 0.0% H0015 Intensive Outpatient Program 53 7009 0 0 0.0% CONFIDENTIAL Page 159 ?fg State of New Mexico ll I Human Services Department Behavioral Health Provider Audits PUBLIC IINC Final Report oltour H2015 H0, HN, 23 l94l 7 565 30.4% T1007 Behaworal Health Treatment 4 509 2 289 50.0% Plan Update Grand 150 4 855 6.0? Total 13?? 9 Sic?ci?E?R?aiaom SamplaleviEWTi?'dings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 160 it?? 0 ll PUBLIC CONSULFING H2015 H2015 H2015 H2015 I H2015 H2015 H2015 11007 i T1007 GROUP Pass Pass Pass Pass Fail NA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report see below. see below. see below. Pass Pass Pass Pass NA Fail NA NA NA Missing staff: 5 not on the provided staff list, is missing credentials per the staff list. missing staff: Pass Pass Pass Fail NA Fail NA NA NA Missing documentation: 1.5 hours billed for a face to face where the progress note does not indicate and progress or application of interventions. it appears to be one sentence, asked if she had maintained her recovery'. Missing staff: _is not found on the provided list. Pass Pass Pass Fail Pass NA NA 6 units not lusti?ed by note. Fail Fail Fail Fail NA Fail NA NA No documentation received for 10I2412012. Pass Pass Fail Fail NA Fail NA NA NA Was notlheld in the community was in the Of?ce CSW did not dowment assessment of safety [monitoring of at risk situations. NMAC 3,315.6. Practitioners quali?cations were not submitted NMAC 83315.6. Pass Pass NA Fail Fail NA NA NA Cient did not show up for his appointment on zlzronz NA Fail NA NA NA Fail NA NA Report from provider stating unable to access documentation for 8I1 612010. NA Fail NA NA Fail Pass NA NA Documentation was not submitted showing the need for continued therapy. Discharge planning with projected discharge date. No other progress notes for that day were submitted. Will need to check claims. CONFIDENTIAL Page I61 A A ?rs 4% A State of New Mexico I Human Services Department 0 I Behavioral Health Provider Audits PLllil 1C against" Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that pepulation. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ 1/2009 - [Bl/2013 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. 0 Partners in Wellness Sample Size ISO Total Paid for Sample $13,214 Sampling Frame Size 24,264 Number of Sample Claims with Overpayments 9 Tentative Overpayment Using Lower Bound of the 90% Con?dence Interval $57.6? Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 162 4% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report GROUP during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: 3 Value Proc Program of Cases Claims 5 Claims Claims Cir 5_ %_,Claims Code Description Reviewed Reviewed Reviewed Failed ?it; Failed H2015 265 23,296 258 22,736 97.4% CCSS Grand Total 5 265 23,296 258 22,736 97.4% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider 0 credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 2 Therapist 6 Clinical Supervisor 1 Community Support Services Coordinator(CSSC) Community Support Worker(CSW) 1 Total Sta?' Reviewed 12 CONFIDENTIAL. Page 163 a?e- A State of New Mexico I I I Human Services Department i i Behavioral Health Provider Audits PUBLIC Final Report Billing System Audit System Overview Partners in Wellness (Pl W) uses the Anasazi application which provides a wide array of components in a??exible display. Anasazi data resides on a Windows?based Server that exists in a ?rewalled subnet on an internal LAN. Client Data in real time which allowing for streamlined quality of care. The Anasazi system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really superficial, such as: The way menus are customized to be di5played per the user roles, 0 How user roles are de?ned, 0 The customization and scheduling of reports and 0 When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most agencies in the Rio Grande system stay one to three behind the most recent release. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. In most situations, staff may choose the Anasazi data they wish to display, and may make changes to this display on-the-fly. Broad functionality is included that provides staff with ready access to information regarding the Client to aid him/her in preparing for different sessions. Application also covers functionality that is common to all of the assessment and treatment plan, assignments, client billing, client payments). Clinician's Home Page functionality: 0 Clinical management complexities all solved in a single screen 0 Over twenty different views to choose from, including client photos 0 Special supervisor access to monitor staff productivity Client Data System functionality: 0 Service Test Recalculation Utility 0 Robust Reporting 0 837P 837i Claim Submission CONFIDENTIAL Page 164 1"?1 A A A State of New Mexico I I Human Services Department 0 Behavioral Health Provider Audits PUBLIC Final Report 0 835 Electronic Remittance Advice 0 Automated Billing Modality and Service Code Assignment Anasazi would not allow PIW (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. IT Contacts: Application Controls - System Administration and Segregation of Duties Agency Administrator Role: Can add users and con?gure data sheets for health plans and 0 services. - Administrative Group: Can con?gure data sheets for health plans and services. Billing Administrator Role: Can convert clinical information into billing information Staff Su ervisor Role: Can see clinical records of clients served clinical subordinates. Service Provider Role: All clinicians who bill and are on the payroll have the Service Provider Role. Auditor Role: No staff at PIW Counseling Services currently have the Auditor Role. IT and Weaknesses 0 PIW clinical and billing system uses the Windows-based Servers that house both the presentation and database layers of the Anasazi system are dynamically updated weekly to ensure the most current Operating System is in place. The Anasazi DB, and related software, is updated and maintained on an as requested/required basis. 0 CONFIDENTIAL Page 165 A State of New Mexico I I Human Services Department Behavioral Health Provider Audits CONSUI IINC. Final Report PIW uses Intrusion Prevention Services UPS) which are provided by the NSA 2400 ?rewall that separates the Anasazi Subnet from the rest of the LAN and lntemet. These database signatures are dynamically updated on a daily basis to ensure industry standard currency is obtained. Anasazi Software has a single-source-code system to allow for ongoing customizations andenhancements. PIW presented disaster recovery plans for the application hosting server and electronic records. Weaknesses: Currently PIW IT staff have little knowledge of the application transaction and database transaction logs. The point of entry to Optum Netwerkes provides the ability to change any billing from what the clinician entered. Recommendations Work with Anasazi vendor to understand the database and application transaction log. Should develop appropriate accounting controls for charge entry/billing in Optum Portal and Optum Networks. CONFIDENTIAL Page 166 ?ns a State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report GROUP Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Partners in PCG Egan and organizers. PCG also reviewed initial founding and leadership information on Pl W. PCG located and reviewed PlW?s audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches 0 on the organization or related individuals. Audit Observations The organization was formed in 2009 and is ?dedicated to providing behavioral healthcare and other administrative and managerial services to health care providers in the State of New Mexico.? The organization is a partnership between Presbyterian Medical Services, Carlsbad Mental Health Center, and Teambuilders. Key Staff Position Last Name First Name Steve Hansen Director Doug Smith Director John Bain Director Noel Clark Director Shannon Freedle Manager Lorraine reedle Manager Financial Relationships CONFIDENTIAL Page 167 WET CONSULI LullOLll' State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Each organization paid in capital to form the company and has been receiving a share of the net income. Carlsbad Mental Health Center has received the following payments from the organization: approximately $333 000 in 2010 and $732,000 in 2011. Summary of Findings and Recommendations These services are primarily funded through Medicaid and the State of New Mexico. Findings Recon: mcmleltiuns One member, Carlsbad Mental Health Center, noti?ed the organization that it planned to withdraw a?er agencies of the State of NM alleged that there were billing irregularities in its own business and subsequently suspended payments to Carlsbad. Carlsbad provided billing, IT support, and staf?ng for PIW. Because of this, the other members asked Carlsbad to withdraw. Management has determined that billing errors were possible due to programming errors which may be a material liability in excess of 100k. Adequate internal controls over billing should be implemented. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2011. 2010 Form 990 (Nonpro?t ?ling) 2011 CONFIDENTIAL Page 168 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC IING Final Report GROUP Balance Sheet 201 I Assets Cash cash equivalents 383,888.00 Contract billings receivable, net of allowances 126,672.00 Program, o?ice equipment 5 29,532.00 Less accumulated depreciation (4,799.00) Prepaid expenses 3 4,5 0.00 So?ware license 5 I 95.00 Less accumulated amortization (17,065.00) Total Assets 5 573,933.00 Liablliti Accounts Payable 6,403.00 Total Liabilities 5 6,408.00 Net Assets 3 567,525.00 Total Liabilities and Net Assets 573,933.00 CONFIDENTIAL Page I69 ??Ss 4% State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSUI IING Final Report Income Statement 2011 Revenue Governmental exchange contracts 878,096.00 Medicaid fees 3 I 17,879.00 Other service fees 16,497.00 Contributions, in kind 3 376,500.00 Rental income 3 9,936.00 Other income 5 720.00 Total Revenues and Support 1,399,628.00 Expenses Program services 3 1,053,778.00 Management general 5 274,034.00 Total Expenses 1,327,812.00 Change in Net Assets 71,816.00 Net Assets, beginning of year 495,709.00 Net Assets, end of year 567,525.00 CONFIDENTIAL Page 170 Pathways Inc. Clinical Narrative IT Narrative Enterprise Narrative . PUBLIC CONSULJ INC GROUP 4% State of New Mexico 9 Human Services Department Behavioral Health Provider Audits PUBLIC Final Report PATHWAYS BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit February-27 ?March 37-20 l3 Dates of Onsite Review- Main Point of Contact at Facility Extrapolatcd Date of Service Overpayments $3,l38,735 Actual Longitudinal Overpayments $55,521 Total Overpayments $3 94.256 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate Provider Scorecard Signi?cant un- This scorecard result translates to the following Risk Tier: 3 Signi?cant ?ndings, including 0 Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. 0 Potentially embed clinical management to improve processes. CONFIDENTIAL Page l7l as A State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits I?le It. CONSLILHNG Final Report 0 Potential change in management. Provider Overview Pathways Inc, Mental Health Services is located in the Albuquerque metropolitan area; it has two Locations in Bernalillo County. Within these locations, Pathways delivers behavioral health services including counseling and services for individuals, families or groups, medication prescription services, medication support services, comprehensive community support services, rehabilitation groups, and crisis services for adults. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 5 Claims Paid FY12 5 Claims Paid Audit Period BHSD 316,780 1,419,434 CYFD 0 0 Medicaid FFS 45,651 159,953 (3 Medicaid MCO 1,935,208 6,033,921 NMCD 0 0 Other 0 0 Grand Total 2,297,639 7,623,308 Audit Team Observations 0 On Wednesday, February 27th, PCG conducted an entrance conference with the upon arriving onsite, explaining the reason we were there, what we needed to review, and the anticipated sequence of events, in addition to answering her questions. 0 FCC received their first case ?le within l5 minutes and reviewed the ?le with - - to ensure all requested documentation was present. The ?le was provided in physical format and was supplemented with additional requested documents within 30 minutes of the initial receipt of the ?le. CONFIDENTIAL Page I72 4% A State of New Mexico Human Services Departtnent Behavioral Health Provider Audits PUBLIC CONSULIINC Final Report 0 Following a 3 hour wait for additional documentation, PCG approached to request additional documentation. informed PCG that she was working on gathering documentation but would not have any additional documentation until the following day. 0 On Thursday, February 28th, PCG waited until 3 pm and had yet to receive any additional documentation, despite several requests. PCG approached and the ml? and reasserted their need to see documentation. At that point informed PCG that it would be l0 business days before we would be able to receive any supporting documentation for the requested claims. PCG's audit team lead was told that we would need to speak to their CEO if wanted documents sooner than that. PCG's audit lead informed the- that PCG would be contacting the State and Pathways' CEO. PCG's team has left the provider site for the day. I PCG's audit team lead reported a Trigger Event - "After Entrance Conference, decline participation") to the FCC project manager, who then reported this to the state at 5:33 pm on the 28th. 0 On the morning of Friday, March lst, the FCC audit team lead who was onsite at TeamBuilders spoke with their who indicated that there was no reason for FCC to have to wait I0 days to receive the requested documentation. 0 Shortly thereafter PCG's audit team lead at Pathways received a call from_, who was very apologetic and said that it was not their intention to keep things from PCG but that ?things were a mess? at Pathways and that she was trying to make sure she can ?nd everything that was requested. I At ll am on the ist, PCG submitted another HSD letter to and which required them to begin turning over documentation by 1 pm that day. 0 By l2:45 pm, PCG had received an additional 3 ?les electronically and was promised at least 20 more by the end of the day. 0 On the afternoon of Friday, March lst, PCG met with the Pathways billing manager who walked PCG through the adjudication of clinical notes with billing outputs. Later that afternoon, PCG met with the Pathways HR manager who updated PCG on the status of pulling staff records and walked PCG through the process of pulling each record from their system. CONFIDENTIAL Page I73 an A A ?g A State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits mm It CONSLII IINC. Final Report (.I - On Monday, March 4th. met with_ and - to review their billing and clinical systems, including inputs, outputs and audit trails. 0 By Monday, March I lth, Pathways had provided the rest of the requested documentation in a neat, well-organized electronic format. 0 Clinical Reviewers noted the following generaHindingsr 0 Safety Assessments were frequently missing for consumers who were assessed to have current or past suicidal ideations (SI), homicidal ideations (HI), self harm or domestic violence issues. 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were incomplete of critical information for the date of service under review. 0 Treatment plans were missing, not up to date. and/or not individualized per consumer. 0 Progress Notes/Recipient Documents were missing. incomplete, and insufficient of necessary information. 0 Random Date of Service Claim Review PCG reviewed one hundred and ?fty (ISO) random date of service claims for July I, 2009 through January 2013. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: of 8 Value 5 Value "2:32" Program Description Claims Claims #lgls?igs Claims %Fg:l:i :15 Reviewed Reviewed Failed 90804 Outpatient?2080 minutes i 43 0 0 0.0% 90806 Outpatient?45-50 minutes i 67 0 0 0.0% 90808 Outpatientw-?IS-SO minutes i 80 0 0 0.0% 90846 Family Therapy 1 67 0 0 0.0% 9084? Family Therapy 2 155 0 0 0.0% 90853 Group Therapy 24 0 0 0.0% CONFIDENTIAL Page I74 State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report GROUP 90862 Medication Management 2 I28 0 0 0.0% H0031 Mental Health Assessment 2 808 0 0 0.0% ?mm RN Medication Monitoring 22 1,094 0 0 0.0% H2015 H0. HN, 88 5.002 76 4, l23 86.4% m0]? Rehabilitation 29 1,056" 219 ?lls m" 150 8,525 83 4,343 55.3% Total Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page I75 I State of New Mexico Human Services Department ll Behavioral Health Provider Audits PUBLIC. Final Report ZROU .. Consent Progress Billing Staffing Pharma Other Comments Notes Forms Recipient Assessment Treatment Service DOS i Screening Plan Delivery Missing infomed consent documents found in file. Missing information: last record of his fist of medications is in H2010 Pass Pass Pass Fail Pass Pass Fail NA NA documentation from 2010. no documents found. only dates of service documents are medication assistance with an RN. Telephone call from client to staff at the community mental health center. Missing credentials for? H2015 Pass Pass Fail Pass NA Pass NA NA NA Staff made telephone call to a housing resource for application. H2015 Pass Pass Fail Pass NA Fail NA NA NA Staff worked on Treatment Plan-inappropriate billing. Staff H2015 Pass Pass Fail Fail NA Fail NA NA NA worked on Treatment Han-inappropriate billing. Missing - credentids for H2015 Pass Pass Pass Pass NA Fail NA NA NA Missing oredentialsfor? H2015 Pass Pass Pass Pass NA Fail NA NA NA Missing credentials for? H2015 Fail Pass Pass Fail NA Pass NA NA NA Missing documentation of client's risk assessment. Missing documentation of client?s risk assessment. Missing H2015 3' Fail Pass Pass Fail NA Fail NA NA i NA documentation of end time to support amount of units billed. I . Missing credentials for - CSW did not document assessment of safety [monitoring of at H2015 5 Pass Pass Pass Fart NA Fail NA NA I NA n'sk situations. ?is not credentialed according to - the provider list. H2015 Pass Pass Fail Fa" NA Fa? NA NA NA Telephone documentation of clients . assessment Missmg credentials for H2015 Pass Pass Pass Pass NA Fail NA NA NA -is not credentialed according to the provider list. CONFIDENTIAL Page 176 ?g Ill PUBLIC CONSULTING 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 Pass Pass Fail Pass NA Fail NA NA NA Telephone contact wlclienl.?is not credentialed I according to the provider list. H2015 . Pass Pass Fail Fail NA Fail NA NA NA Telephone contact wlpatienL Missing documentation of client's risk assessment. is not credentialed according to the provider list. H2015 Pass Pass Fail Fail NA Pass NA NA NA Billed units for comprehensive assessment, not any CCSS services. H2015 Pass Pass Fail Fail NA Fail NA NA NA Missing progress note for this date of service. H2015 Fail Pass Pass Fail NA Fail NA NA NA Missing documentation of client's risk assessment. Missing credentials fo_ Missing documentation of a risk assessment. . Pass Pass Pass Pass Pass Pass NA NA Fail Fail NA NA NA NA NA NA -is not credentialed according to the provider list. Missing dowmentation of client's risk assessment. Missing credentials for? Pass Pass Fail Pass NA Pass NA NA NA No contact with client. staff worked on crisis plan for ctient. Pass Fail Pass Pass NA Pass NA NA NA Missing: ?No initial treatment plan found. Just an updated recovery plan. Pass Pass Fail Fall NA Fail NA NA NA The note for this DOS does not pertain to said client. The note tor this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said client. The note for this DOS does not pertain to said cilent. The note for this DOS does not Page 177 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Repon I I pertain to said client. Telephonmis highlighted in red on H2015 . Pass Pass Fail Pass NA Fail NA NA NA providers list and unknown written across the page for 5 quali?cations. 1 unit bil ed for transporting client?inappropriate billing. .is credentialed according to the provider list. Client made contact with staff via telephone to reschedule I appointment. No documentation to assess client's risk. H2015 1 Fail Pass Fail Fail NA Fail NA NA NA Documentation does not support amount of time spent on phone i 3 5 call. ?is not credentialed according to the provider 1? 3 list. No documentation to assess client's risk. I i . . Missing documentation to support client's progress or lack of I i a Pass Pass Pass Fail NA Fail NA NA NA progress. Missing credentials for_ Stall ti ated crisis lan wlo client. Stall updated crisis plan wlo M15 ?1 Pass Pass Fail Fail NA Fail NA NA NA client. is not credentialed according to the provider?list. H2015 f, i Pass Fail Fail Fail NA Fail NA NA NA H2D15 Pass Pass Fail Fail NA Fail NA NA NA Missing progress note for this date of service. H2015 r: I Pass Pass Pass Pass NA Fail NA NA NA -s not credentialed according to the provider list. H2315 . Pass Pass Fail Pass NA Pass NA NA NA Client called CSW to request individual session. Pass Pass Pass Pass NA Fail NA NA NA Missing quali?cations for - Client call CSW at community mental health center-?' .5 not credentialed according to the provider list. Fail NA NA NA NA Pass NA NA NA Missing 'all documentation for this client. Pass Pass Fail Pass NA Fail NA NA NA Pros. Reciient Assessment Treatment Service Ps?chl .. . Con en 1 Billing Staffing Pharma Other Comments Code DOS [Screening Plan Delivery Progress CONFIDENTIAL Page 178 A A A PU BLIC CONSULTING GROUP H2015. Pass Pass Pass Fail NA Fail NA NA 0 State ct" New Mexico Human Services Department Behavioral Health Provider Audits Final Report Missing documentation of risk assessment done on this date. Missing credentials for - H2015 . Fail NA NA NA NA Pass NA NA NA Missing all documentation for this client. Fail NA NA NA NA Pass NA NA NA Missing all documentation for this client 112015 . Pass Pass Fail Fail NA Fail NA NA NA Client made telephone contact wisecretary. 1 unit billed is not supported by documentation by secretary who received phone call from client requesting name of CCSS worker. secretary of facility received call from staff. Fail Missing all documentation for this client. Fail Missing documentation for this client. Pass Pass Pass Pass NA Fail NA NA NA Missing credentials for Pass Pass Pass Pass NA Fail NA NA NA -is not on the provider list. Pass Pass Fail Fail NA Fail NA NA NA Telophcne call from clie documentation of client's risk assessment. 3 not credentialed according to the provider list. H2015 i Pass Pass Pass Fail NA Pass NA NA NA Staff updated client's crisis plan wlo client. billed 1 unit. Missing documentation of client's current risk assessment. Missing Pass Pass Pass Fail NA Fail NA NA credentials rar? Missing documentation of client's risk assessment. Missing: Provider ?is not credentialed according to the provider list for this agency. H2015 Pass Pass Fa? Pass NA Pass NA NA NA Client called CSW at the Community Mental Health Center. CONFIDENTIAL Page I79 PUBLIC. CONSULI 4% GROUP State ofNew Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 H2015 - lootsi H2015 I H2915 H2015 - I. Pass Pass Fail Fail Fail NA NA NA Telephone contact by CSW to change appointment. Missing documentation of client's risk assessment Documentation does not support the 2 units billed for a phone call to change appointment. Missing credentials for! Pass Pass Fail Pass NA Fail NA NA NA Progress note states that the intake and assessment were completed at this time. Missing credentials for- Pass Pass Fail Pass NA Fail NA NA NA Contact made through a phone call from the consumer.-? -is not credentialed according to the provider list. Pass Pass Fail Fail NA Fail NA NA NA contact made by telephone call. 10 Units billed is not supported by documenation in note dated 10/16/2010 for 2 units. Missing credentials for_ Missing credentials for - - Pass Pass Pass Pass Fail Fail Fail Pass NA NA Pass Fail NA NA NA NA NA Unknown how contacted but it was not face to lace. 3 units billed not supported by documentation of the phone catl. Telephone call made with no contact. Missing credentials for Fail documentation found for this client. Pass Pass Pass Fail NA Fail NA NA NA Missing documentation of clients risk assessment. Missing documentation of end time for activities. therefore, unknown how many units were used and should be billed. Missing credentials tor- Fail NA NA NA NA NA NA Missing all documentation for this client Fail Missing all documents for this client. Fail NA NA NA NA NA Missing all documentation for this client. CONFIDENTIAL Page 180 f??N PUBLIC CONSULTI NC GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report inane Pass Pass Fail Fail NA Pass NA NA NA Telephone contact documented. Missing documentation of client's risk assessment. .Hzoisi Pass Pass Pass Pass Fail NA NA NA Missing credentials for Missing credentials for H2015 Pass Pass Fail Pass NA Pass NA NA NA Telephone contact with client to reschedule appointment. Pass Pass Fail Pass NA Pass NA NA NA Client called CSW at of?ce. H2015. Pass Pass Fail Fail NA Fail NA NA NA Missing: Service date note is of a Diagnostic interview by another provider. No documentation of a CCSS service. Missing: Service date note is of a Diagnostic interview by another provider. Another staff completed the diagnostic interview. Pass Pass Fail Fail Pass NA NA NA Missing progress note for this date of service. Pass Pass Fail Pass NA Fail NA NA NA Wm the contact was made. Missing credentials for Pass Pass Pass Pass NA Faii NA NA NA Missing credentials for - Pass Pass Pass Pass Fail NA NA NA -s not credentialed according to the provider list. Pass Pass Pass Fail NA Pass NA NA NA Minimal documentation. Pass Pass Pass Pass NA Fail NA NA NA Missing credentials for - Pass Pass Pass Fail NA Pass NA NA NA Missing documentation at client's risk assessment. CONFIDENTIAL Page 18] ?g A PUBLIC CONSULI GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 Pass Pass Pass Pass NA Fail NA NA NA -is not credentialed according to the provider list. H2015 Pass Pass Pass Pass NA Fail NA NA NA Missing credentials for H2015 Pass Pass Pass Pass NA Fail NA NA Missing credentials for H2015 Fail Pass Pass Fail NA Fail NA NA NA Missing documentation of client's risk assessment. Missing credentiais for? H2015 Pass Pass Pass Fail NA Fail NA NA Missing documentation of client?s risk assessment. Missing credentials for? H2015 Pass Fail Pass Fail NA Fail NA NA NA Missing documentation of client's risk assessment. Missing credentials for - No Treatment Plan documented during service date time frame. Tx plan documented is for 3/31110 and 814/10. H2015 Pass Pass Fail Fail NA Fail NA NA NA Telephone contact. Missing documentation for client's risk assessment. ?is not credentialed according to the provider list. H2015 - Pass Pass Fail Pass NA Fail NA NA NA Telephone contact with client. Missing credentials for - H2015 Pass Pass Fail Pass NA Fail NA NA NA CSW contacted family member to determine the location of client and will close the case as client is incarcerated. Missing credentials for? H2017 Pass Pass Pass Pass Fail Pass NA NA NA Missing documentation of end time to support amount of units billed. H2017 Pass Pass Pass Pass Pass Fail NA NA NA Documentation does not support this. H2017 Pass Pass Pass Pass Pass Fail NA NA NA Missing documentation of this; not specified. H2017 Fail Pass Pass Pass Fail Pass NA NA NA Missing documentation of end time to support amount of units billed. 05: Missing documentation of client's risk assessment. CONFIDENTIAL Page 82 0 WW PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2017 Fail Pass Pass Pass Pass Pass NA NA NA Missing documentation of dient's risk assessment. I Fail Pass Pass Pass Pass Pass NA NA NA Missing documentation of dienl's n'sk assessment. H2017 Fail Pass Pass Pass Pass Pass NA NA NA eval is not signed. CONFIDENTIAL Page 183 ?g ?ll Ill ILCONSUI lle. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn From a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/l2'2009 l/20l 3 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of' the 90% con?dence interval. Earring Sample Size Total Paid for Sample $8,525 Sampling Frame Size 131,785 Number of Sample Claims with Overpayments 83 Tentative Overpayment Using Lower Bound ol' the 90% Con?dence Interval $39l381?735 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page l84 ail-s" I PUBLIC State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report during calendar year 20l2. Below is a table showing the relevant programs that were included in longitudinal lile review and the resulting ?ndings: Value Proe Program of Cases Claims 8 Claims Claims 0 i Claim Code Description Reviewed Reviewed Reviewed Failed Fifi": Failed more RN Winn? 673 35,768 395 19,782 58.7% Monitoring HO, HN, HM - H20l5 CCSS 5 448 26,788 429 25,564 95.8 H2017 Rehabilitation 5 1,541 80,682 192 i0,l75 l2.5% Grand Total [5 2,662 [43,238 1,016 55,52] 38.2% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 19 Therapist 8 RN 2 I Rehabilitation 8 Unknown/Other Total Staff Reviewed 39 CONFIDENTIAL Page 185 4% A a State of New Mexico Human Services Department II Behavioral Health Provider Audits PUBLIC Eg?d??l IING Final Report Billing System Audit System Overview Pathways uses El Perico as their Electronic Health Record and Practima as their billing system for their 18 sites. They interface with the Optum portal to submit their bills for processing and payment. The IT department at Pathways supports 18 different sites. Both El Perico and Practima are supported by their respective vendors at Pathways. coordinates system administration. El Perico is a program management system designed and developed by ECS, a software development company. The system is hosted and maintained at a data center managed by Synergetic Systems Management. They are responsible for system backups and system uptime. The Practima billing system is used by less than IO providers in the NM area. The product is supported full time by the creator of the Practima billing system. Practima has basic checks for coding inconsistencies. It also is able to generate and audit trail. However it is not tied to the Optum Netwerkes portal which is a common theme at all providers audited. There is a handoff between the intake, eligibility, EHR, billing system, and Optum. At any one of these points errors could be introduced even with the human double checking processes that Pathways has instituted. The systems at Pathways are not well integrated which increases potential for data entry errors between the data intake system and the billing system. Bill process The process from data intake to billing was described to be the following: I) Data intake information and progress notes are entered into the El Perico system. 2) After the progress notes are approved they are printed out and scanned into Intact, a document management system. 3) After scanning the printed data from El Perico is used to enter the information necessary for billing into Practima. 4) Practima interfaces with Emdeon a widely used eligibility system) to verify eligibility. 5) Practima interfaces with Optima Netwerkes to submit the requests for payments using the 837P format. CONFIDENTIAL Page l86 as A: State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSLILI INC GROUP Final Report Pathways has a fully documented training system for all levels of staff and standard treatment paths that the clinicians will face. At every step of the intake thru to the billing process, every step is double checked for accuracy. IT Contacts and roles Application Controls - System Walkth rough Administration and Se re ation of Duties User Roles: ?is able to set login privileges for staff members to restrict access to patient?s information. She also is the manager who is able to set login privileges for staff members to appropriately restrict access to parts of the Practima system. and Weaknesses Have an EHR system that they use to record and track clinical records. Have extensive training for every type of employee and diagnosis. Have initial training and training updates. Each step of the billing process from intake to submission is double checked by at least one other person. Have a disaster recovery plan. Have strong eligibility checking process, training and system. Have strongly documented intake process for new patients. Have strongly documented process for submitting billing claims in batch process on regular basis to avoid duplicate billing. Have an internal audit person who monitors billing trends by region, diagnosis and providers to identify inef?ciencies or outliers that could be fraudulent. Weaknesses: The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. Both the data intake and billing systems log database and application information. But due to the amount of transactional information in the logs it might be dif?cult to ?nd a singular log entry responsible for a questionable transaction. CONFIDENTIAL Page 187 A r?x WT Ill PUBLIC CONSLII IINC. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report I There is no direct connection between the system and the billing system which could lead to human error in transcribing. 0 Did not have a thorough termination plan for employees and their computer system access privileges. - There is no complete audit trail of the entire clinical and billing transaction that is guaranteed to correspond to what is billed to Medicaid Recommendations 0 Should develop appropriate accounting controls for charge entry/billing in Optum Portal. CONFIDENTIAL Page 188 A A State ol? New Mexico 0 I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI Final Report (.Itour Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Pathways, Inc. PCG began by locating Pathways? legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on Pathways. PCG located and reviewed Pathways? audited financial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the Financial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally. PCG performed media and court record searches 0 on the organization or related individuals. This provider had a multi-year connection with Teambuilders Counseling Services. in a complex and evolving relationship, Pathways, Inc., is now controlled by Teambuilders. PCG simultaneously compared reporting from both entities. Key Staff Nancy Colella President Steve Pino Treasurer Debbie Dziak Director Joy Schick-Southwick Consumer Rep Patricia Reedy Consumer Rep Donald Naranjo Exec Director Gabriel Campos Board member Shannon Freedle President/CEO Financial Relationships CONFIDENTIAL Page 189 4% A ?g A State of New Mexico I Human Services Department I Behavioral Health Provider Audits against? Final Report During FY 2011, TeamBuilders Counseling Services provided an unsecured mortgage to Pathways payable over 3 years at 5% interest. In FY 2012, this loan changed, becoming a line of credit secured by the organization?s assets. A second line of credit was established for $80,000 and is also secured by the organization?s assets. During FY12, Pathways paid $87,000 to TeamBuilders of?cers. Summary of Findings and Recommendations Findings In FY12, Pathways paid TeamBuilders These of?cers should be evaluated for of?cers as follows: con?ict of interest, inurement, excess bene?t 0 Shannon Freedle, CEO - $29,207 or private bene?t based upon these 0 Lorraine Freedm, CCO - $ 4,344 transactions. These individuals should be . Ben Lucas, CFO - $13,132 evaluated to determine if they are disquali?ed - Sun Vega, COO - $24,157 Persons- At 6/30/2012, Pathways contracted with a These new accounting ?rms should be Texas-based audit ?rm, Salmon, Sims for evaluated for private bene?t. their audited ?nancial statements and with a Kerrville, TX ?rm (where TeamBuilders? brother is a partner) for preparation of the organization?s tax returns. At 6/30/12, the loan balance to TeamBuilders These transactions to and from Teambuilders was listed at $290,000. Invoices from should be evaluated for con?ict of interest, Teambuilders were listed at $185,000. inurement, excess bene?t or private bene?t. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 20 2011. 201.0. Form 990 (Nonpro?t ?ling) 201 1 Third-party contracts Service agreements Org charts CONFIDENTIAL Page 190 (J AA PUBLIC (.llOUl? ITITI Balance Sheet Assets Cash cash equivalents Accounts receivable l'repaid expenses Cash equivalents - reserved for long- use furniture equipment. net Other assets Service l'ccs receivable Land Investment Total Assets Liabilities Accounts Payable Accrued expenses Notes payable. current portion Notes payable. less current portion Accrued pension contribution Accrued compensated absences Accrued payroll Accrued payroll taxes Notes payable. long-term portion Lines ol'eredit due to related party Total Liabilities Net Assets Total Liabilities and Net Assets 200') 28.366.00 121.15.20.00 5 1 1276.00 3 (0.452.110 22.387.996.00 5 2.17900 2,613,089.00 34.776.00 16.808.00 I 4 .905 .00 3 L7 I 3.603 .00 2,007,092.00 605,997.00 2,613,089.00 2010 578.398.00 210.168.00 3 3.87800 5 6 .45800 2.266.907.00 5 2.17900 5 3,122,988.00 48.00100 3 654,762.00 75.44100 3 1.735.039.00 2,513,245.00 609,743.00 3 3,122,988.00 State of New Mexico Human Services Department Behavioral Health Provider Audits 2011 l3 l0.00 134,388.00 6.645 00 if) 2. 6l.112.00 63.645.00 599951 5 2,497, 00.00 89.28100 3 . 77.959.00 5 - 33 29.51900 3 41.935.00 46,617.00 5 l.973.00 1.919.596.00 2,216,881.00 280,219.00 5 2,497,100.00 Final Report 2012 149.327.00 5.736.00 5 . 1.263.520.00 5 . l06.372.00 794.218.00 5 1179.00 5 2.32l 352.00 3 l4.203.00 87.9l7.00 ?366355.290.000.00 2,158,475.00 162,877.00 8 2,321,352.00 CONFIDENTIAL Page l9 A 2% AA State of New Mexico . I I I Human Servnces Department Behavioral Health Provider Audits CONSLILI INC Final Report L.ll0Lll' Income Stnlemenl 2009 10m 201 I 2012 Revenue cunlracls I 758 777 00 1,837,956 00 2.005.730 00 2,344,404 00 Gram 307.0! I 00 459,840 00 37! .790 00 - lb 535 00 5 I348 00 - - Im 3 91900 5 2.947 00 785 00 - Miscellaneous/Other support luvcuuc 2.427 00 Own an disposal ul'amcls Total Revenues and Supporl 2.091.345.00 2,302.5! 1.00 2,383,579.00 2.346,83l.00 Expenses Program sun'lccs I 25 00 I 494,146 00 .668,652 00 l.808,309 00 8; general 553,931 00 804.6?) 00 5 l,044,45 655,864 00 Total Expenses 2,432,056.00 2,298,765.00 2,713,103.00 Change in Net Assets 5 (340.7l l.00) 5 3,746.00 5 (329,524.00) (117,342.00) Net Assels. beginning org-ear 946,708.00 605,997.00 5 609,743.00 Net Assets, end of your 5 605,997.00 5 609,743.00 200,2l9.00 l62,877.00 CONFIDENTIAL Page I92 Service Organization for Youth Inc. Clinical Narrative iT Narrative Enterprise Narrative A A . lim PUBLIC GROUP A77 A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULIINC Final Report GROUP SERVICE ORGANIZATION FOR YOUTH BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March I3 19,?20l 3 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $7,856 Actual Longitudinal Overpayments l4,0 8 Total Overpayments $2 I ,874 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate Provider Secured Signi?cant .A an- C?mq?mm?? This scorecard result translates to the following Risk Tier: 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management to improve processes. CONFIDENTIAL Page 217 State of New Mexico Human Services Department I Behavioral Health Provider Audits Final Report CONSLII I Provider Overview Service Organization for Youth provides behavioral health services in Raton, New Mexico. Within these locations, Service Organization for youth, delivers behavioral health services including counseling therapy for groups, individuals and families, prevention services, family services (CYFDa'proteetion services referral required). Juvenile?community correction services (CYFD/juvenile justice referral required), treatment services for youth and their families) and the summer food program for youth employment. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. .u Payer Claims Paid FY12 5 Claims Paid Audit Period BHSD 42,81 1 100,20] CYFD 76,053 289,064 Medicaid FFS 5,601 17,524 Medicaid MCO 209,476 536,283 NMCD 0 0 Other 0 0 Grand Total 333,940 943,073 Audit Team Observations - An entrance conference was held with within minutes of the audit team's arrival onsite. - SOY is in the process of merging with Easter Seals E1 Mirador. Once that transaction is complete, certain functions will be shared among the two organizations and Easter Seals will provide Ql, personnel and most other types of support. Easter Seals will also act as the main billing provider, using their own billing management system, through which SOY would license their program and load billing. - Since SOY does not use EHR, all clinical ?les were provided in paper format. The ?les were well organized. All ?les were provided by_with assistance from his clinical and administrative staff. CONFIDENTIAL Page 218 A State ofNew Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSUI iiNG Final Report 0 -provided hard copy originals from the ?les that were subsequently scanned by PCG onsite staff. The ?les were well organized. 0 Clinical Reviewers noted the following general ?ndings: 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were incomplete_of critical information for thedate_of service?under review. 0 Treatment plans were missing, not up to date, and/or not individualized per consumer. 0 Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and (ISO) random date of service claims for July I, 2009 through January 20l3. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: Procedure . . f? Claims 5 Claims Code Program Claims Claims Failed Claims Reviewed Reviewed Failed a 90301 th'm? Dim? 1 108 0.0% Evaluation 90804 Outpatient?20-30 minutes 22 948 0 0 0.0% 90806 Outpatient?4560 minutes 44 2,905 0 0 0.0% Outpatient with 0 90807 EN 4s_50 minutes 1 88 0 0 0.0 A: 90808 Outpatient?75-80 minutes 4 295 0 0 0.0% 90846 Family Therapy I4 920 0 0 0.0% 90847 Family Therapy 22 L664 0 0 0.0% 90849 Outpatient 24 0 0 0.0% Serv1ces 90853 Group Therapy 21 0 0 0.0% CONFIDENTIAL Page 2 l9 2% A 5% State of New Mexico I Human Services Department Behavioral Health Provider Audits CONSUHINC. Final Report GROUP H0015 intensive Outpatient Program 7 926 0 0 0.0% Mental Health Assessment 4 520 1 BO 25.0% H20l5 H0, HN, 2 95 2 95 100.0% S9482 Family Stabilization Services 5 600 0 0 0.0% ?007 Behavioral Health Treatment 2 220 2 220 'oo'ouo Plan Update Grand 150 10 54 5 445 Total ?8 Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 220 gag mun PUBLIC CONSULTING GROUP Pass Fail NA NA NA mam Pass NA NA NA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H0031?Mental Health Assessment?(NMAC 8.3108; Service TX PLAN WITHOUT A DISCHARGE PLAN. H2015 Pass Fail Fail Fail NA Fail NA NA NA Pass ?2015 Pass Fail Fail NA Fall NA NA NA H2015H0, HN, 8.3155: LOC 8.315.69: Service De?nition)? Missing document: PRACTITIONER: DUP modi?er not indicated. H2015HO. HN, 8.3155: LOC 8.315.69; Service De?nition). PRACTITIONER-L. HWY NA Fail HOW?Behavioral Health Treatment Plan Update?(Service De?nition). Treatment plan update states date of 11110111. This claim indicates 10/18/11. T1007 NA Fail NA NA Fail Fail NA NA NA HOW?Behavioral Health Treatment Plan Update?(Service De?n?ionkmissing document. T1 DDT?Behavioral Health Treatment Plan Update?(Service the estimated length of stay not included. CONFIDENTIAL Page 22l =22: A :g A State of New Mexico Human Services Department 0 i I Behavioral Health Provider Audits PUBLIL (C?Egitilglii Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of' claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/l/2009 ll20 3 Sample Size: Sample size is [50 claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Service Organization for Youth Sample Size ISO Total Paid for Sample $10,854 Sampling Frame Size [2,493 Number of Sample Claims with Overpayments 5 Tentative Overpayment Using Lower Bound of the 90% Con?dence Interval $7.856 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid 0 CONFIDENTIAL Page 222 as A State of New Mexico I Human Services Department I I Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Proe Program of Cases Claims 3 Claims Claims 2:22:12]: Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed 90806 5 229 15,420 1 15 7,778 502% 50 minutes Family S9482 Stabilization 5 182 2 ,600 54 6,240 29.7% Services Grand Total 10 41] 37,020 169 14,018 41.1 A Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed 2 Therapist 9 Total Staff Reviewed 11 CONFIDENTIAL Page 223 A ?fs A State of New Mexico I Human Services Department Behavioral Health Provider Audits CONSLII IINC. Final Report (illOLll' lT/Billing Systems Audit System Overview SOY uses Medisoft software for their billing. Medisoft is a 3rd party, cloud based billing system based on Microsoft technology. Medisoft uses Optum Netwerkes ACH and Optum Portal to submit their bills for processing and payment. All PCs are Bill process Data intake forms are entered into the Medisoft system and electronically scanned and stored on a secure ?le server. Raton sends data intake forms and progress notes to Taos office for billing. Taos office receives forms, scans paper documents and stores them on a file server and then data is keyed into Medisoft. Raton uses an older secondary billing system to manage adult service billing and will convert over all billing to Mediso? later this year. Fee rates come from Optum and the State and are hand keyed into the system. Raton is currently sending Outpatient Service billing to the Taos of?ce and is processing Foster Care house services through the old billing system. IT Contacts - Application Controls - System Waikthrough All data intake information collected on paper and encounter data is entered into the Mediso? 3? party system. The paper forms are keyed in by a small number of staff. The claims are billed on a basis. The El Mirador of?ce is the central accounting of?ce for both Raton and Taos. A?er claims are submitted by Taos and Raton a spreadsheet of their billings are sent t_ and for review. Both of them analyze the billings and review the data for increases or decreases. CONFIDENTIAL Page 224 A State of New Mexico I Human Services Department ex Behavioral Health Provider Audits PUBLIC Final Report lT and Weaknesses The Medisoft software application is provided by a division of Mckesson, a $ 23 billion dollar health company. The Medisoft software is a cloud based, practice management software application that is secure and backed up on a regular basis. Medisoft user names and passwords are not shared and are distributed to individual users. Claims and remittances are sent and received electronically through Networks ACG clearing house. The system has reports to reconcile billings and remittances. None of the staff have access to the billing system source code. Formal training to use the system is provided to the users. Visual inspection of latest rates and corresponding procedure codes that were in the system was done by examining application screens and the data was correct. Weaknesses: The weaknesses identified below are common among all the providers we audited especially the three groups that are organized under El Mirador because they all use the same system and owned and managed by the same central corporation; El Mirador, Taos and Raton. Application controls may be compromised by the following application risks: All data forms are keyed into the application by a few individuals. 0 Despite the application?s data entry edits there is opportunity for data entry error. There should be a periodic audit of the stored electronic form and the corresponding data that is stored online compare of units and procedures) to see if differences exist. There is opportunity for clerical staff to create and manage ?ctitious clients and providers. Independent audits on a periodic basis are needed to verify both the provider and patient and the patient?s condition exists. Recommendations Develop a procedure to verify that billing data in 837s and remittance data in 8355 balance out using the Medisoft accounting reports or other available reports. CONFIDENTIAL Page 225 State of New Mexico Human Services Department 0 I I Behavioral Health Provider Audits PUBLIC Final Report - Develop a procedure to con?rm that billings and remittances match to progress notes and billing data in the Medisol?t system. 0 Create a process to verify that patient treatment documentation stored as an image on the image server matches what is in the Medisoft database on a or quarterly basis to prevent data entry mistakes. 0 CONFIDENTIAL Page 226 A r?H State of New Mexico 0 I Human Services Department Behavioral Health Provider Audits PUBLIC CONSUU INC. Final Report (.mut' Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Service Organization for Youth (SOY). PCG began by locating legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on SOY. PCG located and reviewed audited ?nancial statements and tax data. PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally. PCG performed media and court record searches 0 on the organization or related individuals. Audit Observations Service Organization for Youth (SOY) is a small non-pro?t organization administering services to youth and their families to provide crisis intervention, educational assistance, and placement or referral of youth who need alternative living arrangements. Key Staff Last Name Position First Name Karen Murray President Loretta Encinas Vice President Mark Bayliss Member Suzanne Baze Secretary/Treasurer Ferman Ulibarri Executive Director Serena Lannon Financial Manager Terry Baca Member CONFIDENTIAL Page 227 ?253; A A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSUI lth'. Final Report Financial Relationships A local service agency contributes space for SOY to operate in Raton, New Mexico. SOY is in the process of merging with Easter Seals. Summary of Findings and Recommendations Fimlilws SOY is planning to merge with Easter Seals which will optimize administrative services and transfer billing responsibilities to Easter Seals. denials should be reviewed for possible appeal and recapture of lost revenue. in 2010, auditor noted that there were problems with billing and collecting from Optum Health and recommended more training for staff. List of Key Documentation Reviewed Document/Source Year (if applicable) 2010.2009 2011,2010,2009 Audited Financial Statements Form 990 (Nonpro?t ?ling) Third party contracts OrgL charts CONFIDENTIAL Page 228 (0 2% Hill A ill PUBLIC CONSULI INC GROUP Balance Sheet Assets Cash cash equivalents Receivables - grants, contracts Furniture, ?xtures equipment Less accumulated depreciation Total Assets Liabilities Accounts Payable Retirement withholdings payable Payroll taxes payable Deferred revenue Notes payable Notes payable Operating Capital assets Total Liabilities Net Assets Total Liabilities and Net Assets 2009 38,250.00 5 52,08 .00 263,088.00 (l70,050.00) [83,369.00 3,588.00 30.00 3,002.00 3 25,45 I .00 5 62,6 I 9.00 975.00 (6,634.00) 93,038.00 96.965.00 86,404.00 [83,369.00 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report CONFIDENTIAL Page 229 A A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSLII llNC. Final Report GROUP Income Statement 2009 Revenue Other contributions-in-kind 68,040.00 Special events 8 7,949.00 Interest 1 . 149.00 Net assets released from restrictions 812,056.00 Total Revenues and Support 5 889,194.00 Expenses Community Based Services 173,540.00 Facility Program Total Community Approach 104,085.00 Time Limited Reuni?cation 34,816.00 Summer Food Program 8 140,656.00 Juvenile Community Corrections 70,706.00 Mid-Level Family Preservation 83,907.00 Juvenile Drug Court 87,240.00 Tobacco Use Prevention 90,876.00 Other 5 9,534.00 Fundraising 4,558.00 Management general 81,867.00 Total Expenses 881,785.00 Change in Net Assets (unrestricted) 8 7,409.00 Change in Net Assets (temp restricted) 5 6,000.00 Total change in Net Assets 13,409.00 Net Assets, beginning of year 3 73,195.00 Prior-period adjustments 5 (200.00) Net Assets, end of year 86,404.00 CONFIDENTIAL Page 230 Southern New Mexico Human Development Clinical Narrative IT Narrative Enterprise Narrative ?ll PUBLIC CONSULTING GROUP as A A Slate of New Mexico I Human Services Department . Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report GROUP SOUTHERN NEW MEXICO HUMAN DEVELOPMENT BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March 20l3 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $l 304,140 Actual Longitudinal Overpayments $44,239 Total Overpaymen ts ,348,379 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate Provider Scorecard Signi?cant on- This scorecard result translates to the following Risk Tier: 2 Signi?cant volume of ?ndings that - Provide trainings and clinical include missing documents assistance as needed. - Potentially embed clinical management to improve processes. CONFIDENTIAL Page 23] f??K State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits runuc CONSLII IING Final Report Gnour Provider Overview Southern New Mexico Human Development serves the community of Anthony and Sunland Park. Within these locations Southern New Mexico Human Development delivers behavioral health services including counseling and outreach for children and adults, alcohol and substance abuse outpatient services, 24~hour crisis intervention emergency services, evaluation and diagnostic services and specialized outpatient services. Payer 5 Claims Paid FY12 3 Claims Paid Audit Period BHSD 382,223 1,362,569 CYFD 83,107 30 I ,130 Medicaid FF 4,856 24,954 Medicaid MCO 68l,090 2,838,]99 NMCD 0 0 Other 0 0 0 Grand Total 1,151,275 4,526,852 Audit Team Observations 0 An entrance conference was held with ?shortly after the team?s arrival onsite. She stressed the importance of the team understanding their recordkeeping system and how records are kept to ensure that all available documentation is captured. 0 ?arrived late to the entrance conference and asked questions related to the selection criteria, scope and time frame of the audit, all of which were explained by the audit team. 0 noted that the BHR system does not contain any documents with signatures consent forms) and noted that all patients sign consents separate from the electronic fonn. He also expressed concern about administrative support staff being spread thin. CONFIDENTIAL Page 232 C) 0 Ag Hill PUBLIC CONSULT INC GROUP Random Date of Service Claim Review State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report All billing and clinical records are maintained electronically in a single CMHC-EMR system, so clinical records were extracted from their EMR system and provided via ?ash drive. Supervision notes and HR ?les were provided partly in electronic and partly in paper format. It was noted that has only one contracted therapist at this point in time all other practitioners are employed full time so third party contracts provided would be minimal. Clinical Reviewers noted the following general ?ndings: 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were not up to date for the date of service under review. Treatment plans were missing, not up to date, and/or not individualized per consumer. Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. PCG reviewed one hundred and ?fty (150) random date of service claims for July I, 2009 through January 31, 20l3. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: #ol' 3 Value 3 Value . . Proudure Program Description Claims Claims Claim Claims A Clam? Code Failed Renewed Renewed . Failed Failed 9030] Dwm" 4 403 0.0% Evaluation 90804 Outpatient?20-30 minutes 3 l31 0 0 0.0% 90806 Outpatient?4560 minutes 23 l,596 0 0 0.0% 90808 minutes 2 153 0 0 0.0% 90846 Family Therapy 1 69 0 0 0.0% 90847 Family Therapy 2 38 0 0 0.0% CONFIDENTIAL Page 233 gs State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits PUltt IING Final Report 90862 Medication Management 9 661 0 0 0.0% 99212 Of?ceIOutpatient Visit 37 0 0.0% H0002 Behavioral Health Screening 40 0 0 0.0% Mental Health Assessment 5 L487 2 536 40.0% H2014 Behavior Management Services [4 613 7 341 50.0% H2015 H0. HN, 22 L797 8 670 36.4% H2017 Rehabilitation 5? 5,053 35 3,000 61.4% T1007 Behaworal Health Treatment 6 709 3 375 50.0% Plan Update Grand 150 2 3 . Total 12,893 55 4,9 2 6 7 A Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: 0 CONFIDENTIAL Page 234 PUBLIC CONSULTING GROUP Pass Pass NA NA Fail NA NA NA 0 State ofNew Mexico Human Services Department Behavioral Health Provider Audits Final Report Missing staff from the provider list: - Pass Pass Fail NA NA NA Missing staff from staff list: :eH2014 Pass Fail NA Fail NA NA No documentation of start and end time to support amount of units billed. Staff is not on the provider list. +12014 Pass NA Pass NA Fail NA NA NA Staff is not quali?ed per list. H2014 I Pass Pass Fail NA Fail NA NA NA No documentation of start and end time for EMS activity. Staff is listed as unquali?ed. H2014 g. Pass Pass NA Pass NA Fail NA NA NA Staff is listed as Not Quali?ed. 012014 . Pass Pass NA Pass NA Fail NA NA NA Staff is listed as Not Quali?ed. Pass Pass Pass NA Fail NA NA NA Staff is listed as Not Quali?ed. Pass Fail Pass NA Pass NA NA NA CCSSIBMS assessment does not document length of treatment or contains a discharge plan. H2015 Pass Pass Pass Fail NA Fail NA NA NA No documentation of how much time was spent wlciient, no time in and time out on progress note. CSW does not meet the quali?cation/trainings. H2315 Pass Pass Pass Pass NA Fail NA NA NA Staff is listed as not quali?ed. H2015 Pass Pass Pass Pass NA Fail NA NA Missing staff from provider list: s. A H2015 Pass Pass Pass Pass NA Fail NA NA Staff is listed as Not Qualified. CONFIDENTIAL Page 235 Trim PUBLIC CONSULI INC H2015 Free Code State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Pass Fail Pass Pass NA Fail NA NA NA Missing staff from provider list?(TCESis?not?I addressed in the Treatment Plan. Pass Fail Pass Pass NA Fa? NA NA NA Missing credentials tor? 08: Missing Treatment Plan in ?le. Pass Pass Pass Pass NA Fa? NA NA NA Missing staff on provider list:? Fail Pass Pass NA Fail NA NA Staff is listed as Not Quali?ed. No documentation of a tratment plan in ?le. Pass Pass Pass Pass Fail Fail NA NA NA Documentation does not support 6 units billed. No documentation of starting time or ending time nor is there anything on the progress note of how much was for group. or individual. . No documentation nor evidence of what or whom comprises the treatment team.Staff is not quali?ed or met the required trainings. . Recipient DOS Pass Assessment {Screening Fail P355 Treatment Plan Fail Pass Service Delivery Fail Pass 1 Progress Notes Faii Fail Billing Fail Fail Staffing Pass NA Consent Forms NA NA Pharma NA NA Other NA Missing start and end time for activities. therefore, unknown how many units were used and should be billed. Missin documentation of PSR treatment team members. i - is not on the provider list. Another staff provided the actual group session. Comments Missing nocumentation supporting; PSR not recommended. PSR not on the Treatment Plan. identi?ed tx goals were Cannabis use, Oppositional De?ant DID and Prevention Program. No documentation supporting PSR nor recommended. PSR not on the Treatment Plan. identi?ed tx goals were Cannabis use. Oppositional De?ant BIG and Prevention Program. No documentation of start and end time for activities, therefore, unknown how many units were used and should be billed. Missing credentials for - Client not appropriate for CONFIDENTIAL Page 236 A AA Ta PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report PSR. H2017 Pass Pass Pass Pass Fail i Pass NA NA NA Missing start and end time on the progress note. unknown how many units were incurred as there is no supporting evidence. Missing: _is not on the provider list. H2017 Fail Fail Pass Fall Fail Fail NA NA NA Client not appropriate for PSR. No documentation supporting PSR nor recommended. PSR not on the Treatment Plan. No treatment plan in ?le. Missing a Treatment Plan in ?le. Client not appropriate for PSR. Only documentation of whether it was a group session or individual session. was by the modi?er. No documentation of starting time or ending time. Missing documentation of PSR treatment team members. Pass Pass Pass Pass Fail Pass NA NA arr-r? NA No documentation of start and end time for activities. therefore. unknown how many units were used and should be billed. Staff is listed as not qualified. H2017 Fail Pass Pass Pass Pass Pass NA NA NA CCSSIPSRIBMS assessment does not document this. H2017 Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time for activities. therefore. unknown how many units were used and should be billed. H2017 Pass Pass Pass Pass Fail Pass NA NA No documentation of start and end time for activities, therefore. unknown how many units were used and should be billed. H2017 - Fail Pass Pass Pass Fail Pass NA NA NA Missing documentation to support 8 units billed for this service date. The note states that the clinician looked for the client and could not ?nd him. CCSSIPSRIBMS Assessment does not have axes. H2017 Pass Pass Pass Fail Fail Pass NA NA NA No documentation of start and end time to support amount of units billed. No documentation of start and end time for activities. therefore, unknown how many units were used and should be billed. . H2017 Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time for activities. therefore, unknown how many units were used and should be billed. Staff is listed as not quali?ed. CONFIDENTIAL Page 237 State?of New Mexico Human Department Behavioral Health Provider Audits UBL IC CONSULI INC Final Report GROUP iiT l? .. . Consent Progress Billing Staffing Pharma Other Comments Nokes Forms Recipient Assessment Treatment Service [308 i Screening Plan Delivery . No documentation of start and end time for activities. therefore. H2011 . Pass Pass Pass Pass Fail Pass NA NA NA unknown how many units were used and should be billed. Staff is listed as not quali?ed. Missing Assessment. Missing start and end time for activities, 2 Fail Pass Pass Pass Fail Pass NA NA NA therefore. unknown how many units were used and should be . billed. Missing Assessment. Missing credentials for! I - . Missing Assessment. Missing start and end time for activities. Fail Pass Pass Pass Fail Pass NA NA NA therefore, unknown how many units were used and should be billed. Missing staff from provider list: - Documentation does not support the 24 units billed. No I documentation of start and end time for activities. therefore. H2017 Pass Pass Pass Pass Fa? Pass NA NA . NA unknown how many units were used and should be billed. Staff is not listed in provider?s list. 22 units billed inappropriately as documentation supports 20 units per progress note. Missing start and end time for activities. therefore. unknown how #12917 5' Pass Pass Pass Pass Fail Pass NA NA NA many units were used and should be billed. Staff. - M.A.C.. is not on provider's list. Inappropriate billing of 22 units as no documentation of start and -H2017 Pass Pass Pass Pass Fail Pass NA NA NA end time to su amount of units billed. Missing staff from i provider list a 'i-izoir Pass Pass Pass Pass Fail Pass NA NA NA - H2017 i . Pass Pass Pass Pass Fail Pass NA NA NA Missing staff from provider list:- . No documentation of start and end time for activities. therefore. Pass Pass Pass Pass Fa" Pass NA NA NA unknown how many units were used and should be billed. No documentation of start and end time for activities. therefore. unknown how many units were used and should be billed. Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time for activities. therefore. H2017 Pass Pass Pass Pass Fail Pass NA NA NA CONFIDENTIAL Page 23 8 ?i?ii PUBLIC CONSULTING 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report unknown how many units were used and should be billed. Staff is not on the provider's list. Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time to support amount of units billed. Pass Pass Pass Pass Fail Pass NA NA NA Missing start and end time for activities, therefore, unknown how many units were used and should be billed. Pass Pass Pass Pass Fail Pass NA NA NA Missing staff on the provider list: Fail Pass Pass Pass Pass Pass NA NA NA CCSSIPSR Assessment does not have the 5 axes. Pass Pass Pass Pass Pass Pass Pass Fail Fail Pass Pass documentation of start and end time for activities, therefore. unknown how many units were used and should be billed. Staff is not on the provider's list . Staff is listed as Not Quali?ed. Fail Fail Pass Pass Pass Pass NA NA NA Missing Assessment regarding PRS services. Missing Assessment regarding PRS services. Very generic and minimal tx plan for PSR that addresses nothing speci?c. Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time for activities, therefore, unknown how many units were used and should be billed. Staff is not on the provider?s list. Pass Pass Pass Pass Fail Pass NA NA NA Missing staff from provider list: Pass Pass Pass Pass Fail Pass NA NA NA No documentation of start and end time to support amount of units b?led. Staff is listed as Not Quali?ed. H2011 Pass Pass Pass Pass Fail Pass NA NA NA Staff is listed as Not Quali?ed. H2017 . Pass Pass Pass Fall Pass NA NA NA No documentation of start and end time for activities. dierefcre. CONFIDENTIAL Page 239 ?rm PUBLIC CONSUL NC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report unknown how many units were used and shouid be billed. T1007. NA Pass Missing staff on provider list: - T1007 I NA Fail Missing staff on provider list:? T1007 i NA Fall Client came in for ?rst time for depression. No treatment plan in place yet. Missing a Treatment Plan in the ?le. CONFIDENTIAL Page 240 4% A A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC INC. Final Report RDU Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7! /2009 Il20l3 Sample Size: Sample size is 150 claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% confidence interval. Southern New Mexico Human Development Sample Size 150 Total Paid for Sample $12,893 Sampling Frame Size 52,729 Number of Sample Claims with Overpayments 55 Tentative Overpayment Using Lower Bound of the 90% $1,304,l40 Con?dence Interval Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of mo percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 24l ?52: A r-s State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONISULI INC Final Report (.ILOL i' during calendar year 20l2. Below is a table showing the relevant programs that were included in longitudinal file review and the resulting ?ndings: Free Program of Cases Claims 5 Claims Claims 23:2]: Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed 90806 omp?it'enMS' 5 171 11,749 104 7,092 60.8% 50 minutes CCSS 5 -..4 I76 13,863 78.6 16 I H2017 Rehabilitation 5 899 b21707 170 23,284 18.9% Grand Total 15 1,294 153,007 450 44,239 34.8% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 5 Therapist 9 Prevention Specialist 1 2 Rehabilitation 9 EMS 2 Unknown/Other 3 Total Staff Reviewed 29 CONFIDENTIAL page 242 A State of New Mexico Human Services Department 0 I Behavioral Health Provider Audits PUBLIC CONSULIING Final Report GROUP Billing Systems Audit System Overview Southern New Mexico Human Development is the only provider audited that uses the system CMHC, a product by MSHealth. They do not use the most recent web version they use version 5.5 for Windows. They have been using this system for many years and ?nd that it does the basic steps required to support their business. They have approached and interviewed other vendors such as Anasazi but the purchase price is not within their budget and the additional functionalities would, in their opinion, not be worth the investment. However, they understand that as soon as MSHealth stops supporting CMHC Windows product, they will have to switch to another product and/or vendor. CMHC does not include an EHR capability butjust handles basic billing functions. The intake process and the eligibility process are all handled manually. There is a set of paper A, forms that a new patient ?lls out as part of the intake process. The clinical director is informed L) when there is a new client and decides what therapist is going to see them. Then the clinical director schedules an intake appointment. This intake appointment is created on their calendar software. After intake, the patient is assigned to an individual therapist. Each member of the staff only has system access to their own activities. Bill process Accounts Receivable (AR) generates an EDI ?le for submission. Billing is submitted to Optum Netwerkes twice a month. They upload the billing information to Netwerkes and go to the Netwerkes portal to check on processing results. If there is a problem with a claim being rejected by Optum, they ?rst change the claim at Southern New Mexico Human Development and then upload the changed claim to Netwerkes. They are able to generate an audit trail of the actual bill that was entered and modi?ed within the CMHC system. The IT manager has created a set of validation reports to ensure billing accuracy since CMHC does not have many internal checks and is a bare bones system. IT Contacts CONFIDENTIAL Page 243 ?e A A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC 893%?? Final Report Application Controls - System Administration and Segregation of Duties There isjust one IT person who handles all IT and helpdesk functions for Southern New Mexico Human Development. There are settings within the CMHD system to handle restricted access to ?les at the therapist level. The IT manager has ?supervisor? login Ievcl privileges that allow him to change any ?eld in the billing system for any therapist?s case including progress notes. The IT manager can delete progress notes. Currently, the IT manager removes the ability to delete progress notes after the ?rst month a case is established. and Weaknesses They have created a set of validation reports to help ensure accuracy of the billing information as CMHC is a very basic package without many internal checks. 0 The audit trail for the progress notes and billing information can be generated. 0 Have only a rudimentary disaster recovery plan. Weaknesses: - Very reliant on one person to keep the billing system operational. The IT manager is crucial to the operation of this provider and does not have a backup. 0 There is no ability for an electronic signature in the CMHC system. The staff member types in their name into the notes section at the bottom of the clinical record and then selects the to complete and submit the form. 0 There are some ?elds in the CMHC product that are dependent on each other but the dependencies are not documented. They are just known by the IT manager who also functions as the helpdesk IT manager for the billing staff. 0 The CMHC product does not have that many clients and is a product that is not going to be supported at all in the near future. Right now support is minimal. 0 There is no complete audit trail of the entire clinical and billing transaction that is guaranteed to correspond to what is billed to Medicaid Recommendations 0 Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. - Reconsider upgrading or replacing the CMHC system CONFIDENTIAL Page 244 State of New Mexico 4A A Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Southern New Mexico Human Development PCG began by locating legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on PCG located and reviewed audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches 0 on the organization or related individuals. Audit Observations Southern New Mexico Human Development is a small non-pro?t organized to provide mental health, alcohol, and drug abuse services. Key Staff Vincent Ortega Exec Director Ed Saenz Member Ralph Gallegos Chairperson John Holguin Member Elisa West Member David Garcia Vice Chairperson Demetrious Giovas Member Maria Saenz Financial Relationships CONFIDENTIAL Page 245 a a A State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBUC CONSULI le?C'. Final Report enour Services are received from Rio Grande Behavioral Health Services and Rio Grande Management/Providence. Services are listed, but payments are not detailed (presumably because they are below the threshold of $100,000). The Executive Director is an employee of Providence and received compensation of $128,000 from this related party for the years 2009 through 20l l. contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources functions. The organization does not disclose what it pays for these services. Rio Grande is a provider sponsored network and each organization?s board members serve as rotating members of the board. While Rio Grande Behavioral Health Services receives fees from its members, has also distributed various grants back to its members. In addition, and contract with Rio Grande Management, LLC (RGM), paying an undisclosed amount for management services. These include legal services and the provision of executive management. Providence Service Corporation fully owns RGM. Providence is a large, for profit, national corporation providing government sponsored social services directly or indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. The Executive Director of this organization is an employee of Providence Service Corporation. Summary of Findings and Recommendations Recon] montla tinns Findings ln disclaimers, Rio Grande/Providence Full disclosure of executive effort, member organizations state that management sta?? may have other responsibilities to Providence. These arrangements make it unclear if the executives charged by Providence are part or full time for this organization. Moreover, without full disclosure, it is difficult to determine if the salaries or fees are reasonable. On the surface, the arrangements and amounts paid appear reasonable, but this weak and abnormal public disclosure and may have the effect of masking excessive compensation or bene?ts. In compensation and bene?ts should be revealed for this organization and for its services to Providence Service Corporation. CONFIDENTIAL Page 246 4% Ag State of New Mexico ll I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP addition, these arrangements circumvent federal disclosure requirements for charities ?ling Form 990 and make it dif?cult for the public to benchmark charitable organizations. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 20)] 2. 20111. 2010 Form 990 (Nonprofit ?ling) 2012, 201 1, 2010 Professional services contracts Balance Sheet 2009 2010 201 Assets Cash cash equivalents 620,976.00 8 242,763.00 62,466.00 Certi?cate of deposit 101,951.00 8 102,764.00 3 103,163.00 Accounts receivable, net 143,973.00 129,244.00 12,963.00 Prepaid expenses 34,014.00 - - Property equipment, net 3 2,456,905.00 2,494,936.00 2,336,138.00 Accumulated depreciation (1,064,778.00) 8 (1,140,581.00) (1,039,254.00) Loan fees, net of amortization 5 4,921.00 3 3,847.00 2,773.00 Total Assets 5 2,297,962 .00 1,832,973.00 1,578,249.00 Liabilities Accounts Payable 332,836.00 8 33,500.00 - Accrued annual leave 57,608.00 61,907.00 8 52,850.00 Accrued interest payable 3 - 807.00 609.00 Current portion of long-tenn debt 72,481.00 77,335.00 8 182,515.00 Long-term Liabilities 302,316.00 8 224,948.00 142,772.00 Total Liabilities 765,241.00 398,497.00 3 378,746.00 Net Assets 1,532,721.00 1,434,476.00 1,199,503.00 Total Liabilities and Net Assets 2,297,962.00 1,832,973.00 1,578,249.00 CONFIDENTIAL Page 247 gee State of New Mexico I Human Services Department Behavioral Health Provider Audits CONSLII lle. Final Report Income Statement 2009 2010 2011 Revenue Grants/contracts 813,357.00 5 847, I 71.00 525,924.00 Client fees 974,801.00 910,661.00 .8 905,304.00 ln?kind 52,000.00 66,000.00 66,000.00 Miscellaneous income 42,099.00 35,144.00 18,206.00 Interest income 8 9,137.00 3 5,981.00 4,550.00 Total Revenues and Support 5 1,891,394.00 1,864,957.00 1,519,984.00 Expens Program expenses 8 1,462,969.00 1,549,188.00 1,375,713.00 Admin expenses 337,030.00 354,359.00 3 322,943.00 Fundraising 56,128.00 59,655.00 5 56,302.00 Total Expenses 1,856,127.00 1,963,202.00 1,754,958.00 Change in Net Assets 35,266.00 5 (98,245.00) (234,973.00) Net Assets, beginning of year 1,497,455.00 1,532,721.00 1,434,476.00 Net Assets, end of year 5 1,532,721.00 1,434,476.00 1,199,503.00 CONFIDENTIAL Page 248 gs A AA A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP addition, these arrangements circumvent federal disclosure requirements for charities ?ling Form 990 and make it dif?cult for the public to benchmark charitable organizations. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2012. 20111. 2010 Form 990 (Nonpro?t ?ling) 2012, 201 I, 2010 Professional services contracts Balance Sheet 2009 2010 2011 Assets Cash cash equivalents 620,976.00 3 242,763.00 62,466.00 Certi?cate of deposit 101,951.00 102,764.00 103,163.00 Accounts receivable, net 143,973.00 129,244.00 8 1 12,963.00 Prepaid expenses 5 34,0 I 4.00 - - Property equipment, net 3 2,456,905.00 2,494,936.00 2,336,138.00 Accumulated depreciation (1,140,581.00) (1,039,254.00) Loan fees, net of amortization 4,921.00 3,847.00 5 2,773.00 Total Assets 2,297,962.00 1,832,973.00 1,578,249.00 Liabilities Accounts Payable 332,836.00 5 33,500.00 5 - Accrued annual leave 57,608.00 3 61,907.00 52,850.00 Accrued interest payable 3 - 807.00 609.00 Current portion of long-term debt 72,481.00 77,335.00 182,515.00 Long-tenn Liabilities 302,316.00 5 224,948.00 3 142,772.00 Total Liabilities 765,241.00 5 398,497.00 5 378,746.00 Net Assets 8 1,532,721.00 1,434,476.00 1,199,503.00 Total Liabilities and Net Assets 2,297,962.00 1,832,973.00 1,578,249.00 CONFIDENTIAL Page 247 Southwest Counseling Center Inc. Clinical Narrative IT Narrative Enterprise Narrative PUBLIC CONSULTING GROUP A A A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report mouv SOUTHWEST COUNSELING CENTER BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March 6 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $1,028,069 Actual Longitudinal Overpayments $437,537 Total Overpayments $1 ,465,606 Scorecard results are as follows: Random Sample (,?mnpliancc Rate Longitudinal Compliance Rate Preside:- Sr onward Signi?cant A an- C'i?nqllimw c?mq?m?m This scorecard result translates to the following Risk Tier: 3 Signi?cant?ndingS.including 0 Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. CONFIDENTIAL Page 249 A A AA A State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits l?UlilJL CONSUI lth. Final Report Potentially embed clinical management to improve processes. 0 Potential change in management. Provider Overview Southwest Counseling Center serves a mixed urban-rural area of southern New Mexico; it serves the community of Dona Ana County. Within these locations, Southwest Counseling Center delivers behavioral health services including comprehensive community support services, rehabilitation services, residential treatment services, child and adolescent services and assertive community treatment services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 3 Claims Paid FY12 5 Claims Paid Audit Period BHSD 1,599,314 6,179,388 CYFD 0 87 0 Medicaid FFS 81,681 330,326 Medicaid MCO 2,317,393 8,434,939 NMCD 105301 430852.02 Other 0 3932.72 Grand Total 4,103,688 15,379,526 Audit Team Observations On Monday, March 4th, PCG held an entrance conference with Southwest Counseling?s Upon arriving onsite, explaining the reason we were there, what we needed to review, and the anticipated sequence of events, in addition to answering her questions. PCG began receiving well-organized physical ?les almost immediately and throughout the remainder of the day. CONFIDENTIAL Page 250 0 State of New Mexico I I Human Services Department Behavioral Health Provider Audits ItOt PUBLK CONSULI INC. Final Report Rando On Tuesday, March 5th, PCG met with- and Southwest Counseling?s - to once again explain the reason we were there, what we needed to review, and the anticipated sequence of events, in addition to answering their questions. During this meeting,_ expressed frustration with the state?s audits and indicated that in and- were both committing fraud?also stated that was actively committing fraud because they were diagnosing anyone who came in as needing mental health services stated tharhe wasaware of several patients (typically kids) that Southwest Counseling declined to give a mental health diagnosis who than accepted. He stated that several of the for-profit BH providers in NM bill for clients they never treated. PCG continued to receive well-organized physical documentation from Southwest Counseling for the remainder of the week. On Monday. March I 1th, met with?to review their billing and clinical systems, including inputs, outputs and audit trails. By Thursday, March let, PCG had received all of the requested documentation from Southwest Counseling. Clinical Reviewers noted the following general findings: 0 Comprehensive Clinical Assessments were not always provided to detennine/support medical necessity for the billed service or the provided assessments were not up to date for the date of service under review. 0 Treatment plans were missing, not up to date, and/or not individualized per consumer. 0 Progress Notes/Recipient Documents were missing, incomplete, and insufficient of necessary information. Date of Service Claim Review PCG reviewed one hundred and ?fty (ISO) random date of service claims for July I, 2009 through January 31, 2013. Below is a table showing the relevant programs that were included in random audit sample and the resulting findings: 5 Val us I Procedure . In Claim "e Claims Program Description Claims Claims Claims Code . . Failed Renewed Revrewed Failed Failed CONFIDENTIAL Page 25] 9% A State of New Mexico II I Human Services Department Behavioral Health Provider Audits Punl 1C IINC. Final Report t. lOLll' 90301 2 242 0.0% Evaluation 90804 Outpatient?2060 minutes 3 I32 0 0 0.0% 90806 Outpatient?4560 minutes 23 1.578 0 0 0.0% 90847 Family Therapy 4 3 l3 0 0 0.0% 90853 Group Therapy 21 521 0 0 0.0% 90862 Medication Management 9 573 0 0 0.0% H0019 Transitional Living Services 8 960 0 0 0.0% H0031 Mental Health Assessment 2 833 416 50.0% Assertive Community H0039 Treatment 33 5,843 0 0 0.0% H2010 RN Medication Monitoring 6 450 0 0 0.0% H2011 Crisis Intervention Services 2 241 0 0 0.0% H2015 H0. HN. 13 799 8 5l6 61.5% H2017 Rehabilitation 13 L270 5 364 38.5% ?007 BehaVIoral Health Treatment 7 793 5 568 Plan Update T1024 Resource Management Services 1 l0 1 to [00.0% T1502 Medication Administration 3 45 3 45 l00.0% Grand Total 150 14,601 23 1,919 15.3 /e Specific Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concem. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 252 State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC EEONJISULTING Final Report ., ch Recrpient Assessment Treatment Service I Consent Progress Billing Staffing Pharma Other Comments DOS lScreening Plan Delivery Notes Forms Documentation Missing NMAC 8310.8; Service De?nition: Reviewer unable to read. scanning process did not copy entire H0031 Fail Fail NA NA Pass Fail NA NA NA document. scanning process did not copy entire document Practitioner not on agency roster NMAC 8310.6; Service De?nition. Documentation Missing NMAC 8.3156. Documentation Missing NMAC 8,315.6. Progress note states to see hard copy no copy in ?le. NMAC 8315.6. Documentation does not support units billed NMAC 8,315.6. Provider was not listed on the stall roster submitted. NMAC 8310.8. Documentation Missing NMAC 6.3156. CSW did not document assessment of safety Imonitoring of at risk situations. NMAC 8315.6. Documentation does not support units billed NMAC 8315.6. Treatment plan contains an assessment each time plan is updated. Missing Axes iV. Missing documentation, please see note below NMAC 8.3156. - . . . Documentation in the Anazazi note states there was travel H2015 Pass Pass Fatimeltransportation lime. Provider is not on the agency roster NMAC 6.3156. Missing Documentation for C083 treatmentlservice plan. There is no treatment plan prior to this NMAC 8.3156; LOC - 8.315.69; Service De?nition. Practitioner's quali?cations were not H2015 Pass Fail Fail Fail NA Fail NA NA NA submitted. There is no treatment plan prior to this NMAC 8315.6; LDC 8.315.69; Service De?nition. Practitioners quali?cations were not submitted There is no treatment plan prior to this NMAC 8,315.6: LOG 8.315.69; Service De?nition. Missing Documentation: CCSS service/treatment plan there is a treatment plan however it does not have CCSS goals and H2015 Pass Fail Fail Fail NA Fall NA NA NA H2015 Fail Pass Pass Fail NA Pass NA NA NA H2015 Pass Fail Fail Pass NA Pass NA NA NA CONFIDENTIAL Page 253 LONSLILI INC GROUP ?g Ill State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report objectives they do mention CCSS as an intervention NMAC 8315.6. H2015 H2015 H2015 H2017 H2017 H2017 H2017 H2017 Pass Fail Fail Fail NA Pass NA NA NA 8 min phone can between the CSW and member. NMAC 8.3156. Tx plan uses the CSW as an intervention to help the member be med compliant, provide skill training in budget development and money management skills. Fail Pass Fail Pass NA Fail NA NA Session was face to face. progress note states Provided at Center. CCSS in of?ce NMAC 8315.6; LOC 8,315.69; Service Definition. Reviewer unable to read. scanning process did not copy entire document. NMAC 8,315.6; LOC 8.315.69: Service Definition. Provider is not listed on the agency roster NMAC 8315.6: LOC 8.31559. Pass Fail Pass Pass Fail Pass Pass Pass NA Pass Fail Pass NA NA NA NA NA NA Session with member took place in the CCSS office. NMAC 8.315.6._not on staff roster. he has a ?le in the stalf folder, unable to determine qualifications for providing this service. Missing documentation NMAC 8,315.3. Missing documentation NMAC 8 315.3. Pass Pass Pass Pass Fail Pass NA NA Practitioners quali?cations were not submitted- Fail Pass Pass Pass Fail Pass NA NA NA Missing documentation NMAC 8.3156. Start time 11:30 am Stop time 2:00 duration 2.30 or 10 units. Claims shows 14 units NMAC 8.3153: Service Definition. Missing documentation NMAC 8.3155. Missing documentation NMAC 8.3156. Fail Pass Pass Pass Pass Pass NA NA Missing documentation NMAC 8,315.3; Service Definition. Fail Pass Pass Pass Pass Pass NA NA NA Missing assessment. CONFIDENTIAL Page 254 A 4% Trill PUBLIC CONSULTI NC GROUP 0 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report T1007 NA Fail NA Fail NA NA Missing document: treatment plan that was formulated ON date of service. T1007 NA Fail NA Pass NA NA No signature on the tx plan submitted NMAC 8.3155. T1007 Fail NA Fail Fail NA Missing documentation T1 (JOY?Behavioral Health Treatment Plan Update-(Service De?nition). T1007 NA Fail NA NA NA Fail NA NA NA No discharge planning or projected discharge date on treatment plan. _not on staff roster. he has a ?le in the staff roster. unable to determine if he is quali?ed to render this service. T1007 Fail NA NA NA Pass NA NA NA AXIS I reads none: Member did not sign treatment plan. T1024 Pass Pass Fail NA Fail NA NA NA Documentation Missing. Service Definition-is not on the agency roster. _has been practicing with agency for many ears Service De?nition. T1502 Pass NA NA NA NA Fall NA Pass NA is on progress note. she is not on the staff roster is a has a ?le in staff folder. unable to determine if she is quali?ed to render service. T1502 Fail NA NA NA Fail NA Fail Progress noted dated 10!20f09 10:15 - 10:45 Service: TM Medicat'on Prolixin progress note reads see hard copy. hard copy not submitted. Service De?nition; Progress noted dated 10I20109 10:15 - 10:45 Service: TM Medication Prolixin progress note reads see hard copy. hard copy not submitted. T1502 Pass NA NA NA NA Fail NA _is not on staff roster. she has a tile in the staff folder. unable to determine qualifications to render this service. CONFIDENTIAL Page 255 A a A State of New Mexico I Human Services Department mm Behavioral Health Provider Audits mour- Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of? claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ l/2009 l/3ll?2013 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Southern New Mexico Human Development Sample Size 150 Total Paid for Sample $l4,601 Sampling Frame Size 51,769 Number of Sample Claims with Overpayments 23 Tentative Overpayment Using Lower Bound of the 90% Con?dence Interval $1,023.059 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the five recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 256 A gee-T um l?UBl IC CONSLILIING State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Value Free Program of Cases Claims 3 Claims Claims Claims Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed Assertive H9039 (Immunity 5 1,363 304,900 L327 297,356 97.4% Treatment H2015 5 259 20,230 259 20,230 100.0% CCSS H2017 Rehabilitation 5 976 119,95 I 976 119,951 100.0% Grand Total l5 2,598 445,080 2,562 437,537 98.6% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 6 Therapist 8 Nurse 1 Rehabilitation 3 Unknown/Other 3 Total Staff Reviewed 21 CONFIDENTIAL Page 257 A A A A State of New Mexico I Human Services Department mm Behavioral Health Provider Audits lacur Final Report Billing Systems Audit System Overview Southwest Counseling Center utilizes the Anasazi System for most of its medical records and billing. The system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really super?cial, such as: The way menus are customized to be displayed per the user roles, 0 How user roles are de?ned, 0 The customization and scheduling of reports and I When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most agencies in the Rio Grande system stay one to three updates behind the most recent. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. The software is actually installed on the Southwest Counseling Center Microsoft Window Network but it is primarily accessed through the Citrix system, which allows all administrative and clinical staff to access the system from any computer that is connected to the intemet. Anasazi would not allow Southwest Counseling Center (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. Bill Processing After services are provided to the client, the clinician updates the ?le with notes and the time and date of encounter. The Anasazi software processes this information and calculates the number of units that the service should be billed for, and what code should be assigned to the service, using the service provided and start and stop times of the service. The service is processed by the Anasazi system and transformed into an 837 billing format, which is uploaded using the Optum Netwerkes ACH system. IT Contacts CONFIDENTIAL Page 258 A A State of New Mexico I Human Services Department PUNK. CONSULHM. Behavioral Health Provider Audits ?our Final Report ITITI Application Controls - System Administration and Segregation of Duties There are two systems that SW Counseling users access: the Microsoft Windows Network and the Anasazi System. The Anasazi system is accessible both through the Windows network and through any computer that is connected to the intemet through the Citrix system. For that reason, PCG will only discuss Anasazi access in this report; the Windows network users are held in audit documentation collected by PCG for any required future reference. User Roles Svstem Admin Group: Can add users and con?gure data sheets for health plans and services. 0 Admin? ra Ive roup: Ian conllgure lala slee! 'or lealth plans and services. Medical Records and Intake Groups: Records Clerks and Intake Staff have appropriate administrative levels of access to records; primarily administrative and demographic records and read only for clinical information. Clinical Group: All clinicians who bill are in the Clinical Group. They can enter clinical service provision to the system. Rio Grande Supervisors Group: Staff from Rio Grande Behavioral Health Services have a supervisory user role per their management services agreement with Southwest Counseling Center. Auditors Group: No staff at Southwest Counseling Center currently have the Auditor Role, but they have established Auditor accounts should outside auditors need access. CONFIDENTIAL Page 259 2% A fr? State of New Mexico II Human Services Department mm IL . Behavioral Health Provider Audits uncul' Final Report IT and Weaknesses 0 Southwest Counseling Center?s Anasazi applications are available from any computer connected to the internet via Citrix, which make for ease of use from any computer and maintains a unif0rmly enforced security policy. I- Users do not share login accounts. 0 The Anasazi software offers sequestration of clinical information so that users? roles determine the kind of information each user may have access to on a per client basis. For example, a front of?ce clerk may have access to certain demographic information, but a Each clinician enters his/her own billing information. 0 Each clinician does not know what codes are used for billing the service provided, he/she only knows what service is being provided. 0 In cases of time duration-based billing units, Anasazi software calculates units billed based on start and end times recorded by the clinician. I Anasazi software allows for members of a group therapy session to arrive and leave at different times, allowing for more accurate tracking group services, and therefore billing. Weaknesses: 0 The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. The 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 can make any changes to billing with no audit trail. 0 Training is done mostly on an ad hoc basis. Recommendations 0 Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. 0 DeveIOp formalized training system for all users who create charge entry and billing. CONFIDENTIAL Page 260 4% IA State of New Mexico Human Services Department PUNK COme "Ml Behavioral Health Provider Audits (.mur Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Southwest Counseling Center, Inc. (Southwest). PCG began by locating Southwest?s legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on Southwest. PCG located and reviewed Southwest?s audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches on the organization or related individuals. The organization has an economic interest in its af?liate, Southern Rio Grande Mental Health Foundation. The foundation owns and leases real estate to Southwest Counseling Center, Inc. The economic interest of each organization in the other is suf?cient to allow the pooled ?nancial reporting to be presented as a consolidated organization. We reviewed the consolidated results. Based on this consolidated structure, PCG reviewed consolidated ?nancial documents. Key Staff ldella Cantrell President Marla J. Cooper President Elect rima Marquez Past President Felipe Salcido, .lr Secretary/Treasurer Joyce Montes Member at large Elwood M. Powell Director Roque Garcia Acting CEO Dexter Sandoval COO CONFIDENTIAL Page 26 A 6-1-13 A State of New Mexico I I Human Services Department rum-K Behavioral Health GROUP Final Report Financial Relationships Southwest contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources functions, for which Southwest paid $140,000 in 2010'. Rio Grande is a provider sponsored network and each organization?s board members serve as rotating members of the board. While receives fees from its members. it has also distributed various grants back to its members. In addition, Southwest contracts with Rio Grande Management, LLC (RGM), paying $195,000 (2010) annually for management services. These include legal services and the provision of executive management. RGM is fully owned by Providence Service Corporation, a large, for pro?t, national corporation providing government sponsored social services directly or indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. The Executive Director of this organization is an employee of Providence Service Corporation. In 2010, Director Joyce Montes was paid $162,000; acting CEO Roque Garcia was paid $135,000; and Dexter Sandoval, COO, was paid from RGM. Summary of Findings and Recommendations Recom undo tions Ii In 2010 and 2011, Roque Garcia (CEO of These transactions should be evaluated to served as Acting CEO of Southwest Counseling. Additional compensation was provided for use of an airplane owned by Mr. Garcia. In 2010 and 2011, Dexter Sandoval (CFO of served as COO of Southwest Counseling. determine if these individuals are disquali?ed persons and if any part of the transactions rise to the level of excess benefit. In disclaimers, Rio Grande/Providence member organizations state that management staff may have other responsibilities to Providence. These arrangements make it Full disclosure of executive effort, compensation and bene?ts should be revealed for this organization and for its services to Providence Service Corporation. unclear if the executives charged by I Most recent year for which representative payments for both behavioral health and management services were reported. CONFIDENTIAL Page 262 A a State of New Mexico Human Services Department runm Lovsumm, Behavioral Health Provider Audits mom- Final Report Providence are part or full time for this organization. Moreover, without full disclosure, it is dif?cult to determine if the salaries or fees are reasonable. On the surface, the arrangements and amounts paid appear reasonable, but this weak and abnormal public disclosure may have the effect of masking excessive compensation or bene?ts. in addition, these arrangements circumvent federal disclosure requirements for charities ?ling Form 990 and make it dif?cult for the public to benchmark charitable organizations. List of Key Documentation Reviewed Document/?Source Year (if applicable) 2011. 2010. 2009 20] I, 2010, 2009 Audited Financial Statements Form 990 (Nonpro?t ?ling) Contracts Service agreements ?3 Charts CONFIDENTIAL Page 263 ?57111 111111 l'LIlIl It ll\t . State of New Mexico Human Services Department Behavioral Health Provider Audits mom Final Report Balance Sheet 2009 Assets Cash cash equivalents 1,171,353.00 Accounts receivable. less allowance for doubtful accts of $26.839 1,092,860.00 Inventory 76,914.00 Prepaid expenses 30,958.00 Land 3 190,037.00 Building improvements 4,837,149.00 Origination fees 5 6,790.00 Of?ce equipment 5 917,518.00 Library 4,928.00 Vehicles 348,758.00 Less accumulated depreciation (1,890,129.00) Restricted cash 49,505.00 Deposits 675.00 Total Assets $6,837,316.00 Liabilities Accounts Payable 140,292.00 Payroll taxes other payables 14,150.00 Accrued wages 95,024.00 Accrued annual leave 3 155,785.00 Custodial accounts 49,505.00 Due to others 56,978.00 Deferred revenues 1,026,297.00 Notes payable-current portion I 15,565.00 Notes payable, net of current 3,466,407.00 Total Liabilities $5,120,003.00 Net Assets $1,717,313.00 Total Liabilities and Net Assets $6,837,316.00 CONFIDENTIAL Page 264 a: Hill as: a CONSLILI (.llOUl? Income Statement Revenue State contracts Service fees Local funds ln-kind revenues Interest income Miscellaneous income Total Revenues and Support Expenses Program expenses Admin expenses Fundraising Total Expenses Change in Net Assets Net Assets, beginning of year Net Assets, end of year 2009 3,943,6 7.00 1,524,530.00 26,540.00 3 l2 1,792.00 4, l78.00 [05,085.00 $5,725,742.00 4,061,450.00 l.597,220.00 45,440.00 10.00 21,632.00 $1,695,68l .00 $I,7l7,313.00 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report CONFIDENTIAL Page 265 Teambuilders Counseling Services Inc. Clinical Narrative 1T Narrative Enterprise Narrative ?fi? PUBLIC CONSULTING as A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report GROUP TEAMBUILDERS COUNSELING SERVICES BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit of OnsiteRcview cbruary?27 March 7, 20l3 Main Point of Contact at Facility Extrapolated Date of Service Overpayments Actual Longitudinal Overpayments $335,833 Total Overpayments $9,598,544 Scorecard results are as follows: Random Sample Rate Longitudinal Compliance Ra to 79% 40% Provider Scan-can! Signi?cant A vii- This scorecard result translates to the following Risk Tier: 2 Signi?cant volume of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management to improve processes. CONFIDENTIAL Page 266 A State of New Mexico I I Human Services Department Behavioral Health Provider Audits Final Report Provider Overview TeamBuilders Counseling Services has facilities in ?fty two locations, in seventeen counties in New Mexico. Within these locations, TeamBuilders delivers behavioral health services including behavior management services, comprehensive community support services, individual and family counseling, multi-systemic therapy, services, residential treatment/group home care, sandplay therapy, treatment foster care, support groups and other services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer Claims Paid FY12 3 Claims Paid Audit Period BHSD 474 1,290 CYFD 941,909 2,492,459 Medicaid FPS 1,307,843 4,541,860 Medicaid MCO 22,297,l50 70,782,727 NMCD 15,079 1 55,020 Other 3,633 2] 0,777 Grand Total 24,566,087 78,184,133 Audit Team Observations - An entrance conference was held approximately 90 minutes after PCG arrived onsite. Prior to the arrival of ITeamBuilders_, PCG spoke brie?y wi nd - about the purposes of the audit. When_ PCG conducted the formal entrance conference. introduced PCG to various staff members from his programs teams and his administration functions who would be assisting us with the documentation collection. 0 Case ?les began to arrive at approximately 1:00 pm on the day after arrival onsite. 0 TeamBuilders chose to make copies of all documentation that they submitted to PCG and was very organized and provided PCG with complete case ?les service authorizations, treatment plans, case notes) for the dates of service in the claims sample CONFIDENTIAL Page 267 as State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report on a ?ash drive. The ?les were clearly labeled and each ?le had an index of what was included. Human Resources staff produced documentation regarding staff credentials, training, and supervisory logs approximately four business days after our arrival. Like the case ?les TeamBuilders produced, the staff ?les were orderly and submitted electronically. about claims documentation PCG interviewed and submission. reported that he believed the internal controls to be strong and effective at TeamBuilders. TeamBuilders staff was cooperative and transparent throughout our time onsite. Clinical Reviewers noted the following general ?ndings: 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service. 0 Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and forty-seven (I47) random date of service claims for July I, 2009 through January 2013. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: Procedure (3r 3 will?: Claim 5 ?flue Claims Program Description Claims Claims Claims Code . . . Failed Revrewed Renewed Failed Failed Diagnostic 90801 Evaluation I 90 0 0 0.0% 90802 Interactive 1 I45 0 0 0.0% Evaluation 90806 Outpatient?4560 minutes 17 1,131 0 0 0.0% 90834 Outpatient ?45 minutes I 68 0 0 0.0% 90837 Outpatient?60 minutes 1 7 0 0 0.0% 90846 Family Therapy 5 337 0 0 0.0% CONFIDENTIAL Page 268 2% A State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIL CONSLII llNC. Final Report 9084'] Family Therapy 8 626 0 0 0.0% 90862 Medication Management 6 429 0 0 0.0% H0041 Foster Care(Shelter) 2 200 0 0 0.0% H2014 Behavior Management Services 32 3,398 6 692 18.8% H2015 H0, HN, 33 2.542 24 1,882 72.7% H2017 Rehabilitation 2 238 l02 50.0% H2033 Mum-Systematic Therapy 6 2,795 0 0 0.0% Q3014 Telehealth Facility Fee/Code 6 135 0 0 0.0% 45 Treatment Foster Care 17 2.726 0 0 0.0% T1005 Respite Services 9 435 0 0 0.0% Grand 147 15 66 31 2 675 21.1? Total ?3 A Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 259 PUBLIC CONSULT INC. GROUP H201 4 Pass Pass NA Pass Fail NA NA NA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report HEM?Behavior Management Services(NMAC 8.3223; LOC MSSING DOCUMENT: H2014 Pass Pass NA Fail Pass NA NA NA TIME INDICATED IN THE NOTE: 08:30 TO UNITS BILLING ABOVE NDICATES 13 UNITS. H2014?Behavior Management Services (NMAC 6.3223; LOC 745.2). H2014 Pass Pass NA Pass Fail NA NA MISSING DOCUMENT: for cs_ H2014 Fail Pass NA Pass Pass NA NA NA no Axis appears patient does have seasonal allergies listed. - H2014 Pass Pass NA Pass NA Fail NA NA NA MISSING DOCUMENTATION: Unable to read the practitioner's name. H2015 Pass Pass Pass Fail NA Pass NA NA NA H2015H0. HN. 8315.6: LOC 3.315.69; Service to improve and Include speci?c risk assessment. H2015 Pass Pass Pass Pass NA Fail NA NA NA H2015HO. HN. 8,315.6: LOC 8,315.69: Service provider not quali?ed as per list. H2015 Pass Pass Pass Pass NA Fail NA NA H2015HO. HN. 8.31515; LOC 8,315.69; Service De?nition) not quali?ed as per stall list. Pass Pass Fail Pass NA Fail NA NA NA H2015HO. HN. 3315.6: LOO 8.315.69; Service QUALIFIED PER STAFF LIST. H2015 Pass Pass Pass Pass NA Fail NA NA NA H2015H0. HN. 8,315.6; LOC 8.315.69; Service De?nition. Pass Pass Fail Pass NA Pass NA NA H2015H0. HN. 8315.6; LOC 8.315.69; Service NOTE THIS IS A TELEPHONE CALL. i H2015 Pass Pass Pass Fail NA Fail NA NA NA H2015H0, HN. 8315.6: LOC 0.315.69; Service Definition) H2015H0. HN. 8315.0; LOC 8.315.69; Service De?nition)?PER LIST. PRACTITIONER CONFIDENTIAL Page 270 r?A?e um I PUBLIL CONSULI INC GROUP AT State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report DOES NOT HAVE THE QUALIFICATIONS. H2015HO. HN. H2015 Pass Pass Pass Fail NA Fail NA NA H2015H0. HN. 8,315.6; LOC 8.315.69: Service De?nition-. note indicates that this date the CSW met to conduct the initial assessment with parents. This reviewer questions it there is doubts billing. H2015H0. HN. (NMAC 8,315.6: LOC 8.315.69; Service De?nition?Rendering practitioner not quali?ed as per list. NA H2015 Pass Pass Pass Fail NA Pass NA NA 8315.6 H2015?by reading note. it is implied there are no risk. however. risk assessment ls needed. H2015 5 Pass Pass Pass Fail NA Fail NA NA The time is ?ne. however. the documentation does not re?ect a need for this particular meeting. H2015H0. HN. (NMAC 8315.6; LOC 8.315.69; Service Definition)?per listing. this rendering practitioner does not meet quali?cations. NA H2015 Pass Assessment i Screening Proc Ltecipient Code DOS H2015 1 Pass Pass Pass Treatment Service Plan Delivery Pass Pass Fail Progress Notes Pass NA Billing NA Staffing Fail NA Consent Fonns Fail NA NA Phanna H2015H0. HN, 8315.6; LOC 8.315.69; Service De?nition. H2015H0, HN. 8.3155; LOC 3.315.69; Service code is for a Masters Degree level. the person in the billing has an Associates. NA Other Comments H2015HO, HN. 8315.6; LOC 8.315.69; NA Service De?nition). H2015H0. HN, 8.3.15.6; LOC 8.315.69: Service De?nition). H2015 Pass Pass Pass Fail NA Pass NA NA H2015H0, HN, 8315.6; LOC 8.315.59; NA Service De?nitiothis area of documentation needs to improve. the note provides minimum information. H2015 Pass Pass Pass Pass NA Fail NA NA NA Missin documentation- Can not verify credentiais for. H2015 Pass Pass Pass Pass NA Fail NA NA NA Missing documentation- Can not verify the credential? CONFIDENTIAL Page 27] PUBLIC CONSULTING CROU State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Missin documentation- Can not verify the H2015 Pass Pass Fail Fail NA Fail NA NA NA H2015H0, HN. 8315.6; LOC 8315.69; Service De?nition)?did not see goalslobiectives related to drug/alcohol use. H2015H0, HN. 8315.6; LOC 8315.69; Service De?nition). H2015 Pass Pass Pass Pass NA Fail NA NA NA H2015H0, HN. 8315.6; LOC 8315.69; Service De?nition). H2015 Pass Pass Pass Pass Fail NA NA NA This provider does not meet the requirements as per staff list. H2015H0. HN, 8315.6; LOC 8315.69; Service Definition. H201 5 Pass Pass Pass Pass Fail NA NA This provider does not meet the requirements as per staff list. H2015HO, HN, 8. This provider does not meet the requirements as per staff list. H2015H0, HN. 8. H2015 Fail Pass Pass Pass NA Pass NA NA NA Missing documentation-? LICENSUREICREDENTIALS UNKNOWN. H2015 Pass Pass Pass Fail NA Pass NA NA NA H2015H0. HN. 3.3155; LOC 8315.69: Service De?nition). H2015 Pass Pass Pass Fail NA Fail NA NA NA H2015H0. HN. 8315.6; LOC 8315.69; Service De?nition) documentation needs improvement in this area. H2015 Pass Pass Pass Pass NA Fail NA NA NA This provider does not meet the requirements as per staff list. H2015H0, HN. 8315.6; LOC 8315.69; Service Definition. H2017 Pass Pass Fail Pass Fail Pass NA NA 8.3153 NMAC -not able to determine where this service took place/location. it onty indicated the time, "Group" and the date 9am to 2pm on 11I17f2011i. 8315.3 NMAC. S5145 Pass NA NA Fail Fail NA NA NA NA N0 documentation other services were billed on this DOS. No signature for a clinical staff person located. No safety issues CONFIDENTIAL Page 272 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report GROUP addressed per documentation. .. . Consent Progress Staffing Pharma Comments Fonns Notes Proc Recipient Assessment Treatment Service Code 008 Screening Plan Delivery No signature for a clinical staff person located. Documentation reveals client undenrvent medical procedure and received support from foster parent on this DOS. No safety issues addressed per documentation on this DOS. 35145 Pass NA NA Fail Pass NA NA NA NA CONFIDENTIAL Page 273 State of New Mexico I Human Services Department Behavioral Health Provider Audits I?UllilC ?g??utl th. Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ 1/2009 - 1/20 I 3 Sample Size: Sample size is 147 claims. Cl) Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. TeamBuilders Sample Size 147 Total Paid for Sample 3 5,366 Sampling Frame Size 714,243 Number of Sample Claims with Overpayments 3 Tentative Overpayment Using Lower Bound of the 90% $9 262 7? Con?dence Interval Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 ?3 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 274 a Hill A Ill A ll! PUBLIC CONSLII Ith. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report during calendar year 2012. Below is a table showing the relevant programs that were included in PCG's longitudinal ?le review and the resulting findings: Proc Program of Cases Claims Claims Claims 1132:: Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed Behavior H2014 Management 5 l,214 146,555 300 35,789 24.7% Services HO HN 1 '7 0 H2015 CCSS 5 3l5 -S,3l0 _l7 8,88l 68.923 Multi- H2033 Systematic 5 489 251,910 68 25,524 13.9% Therapy $5145 Treatment 5 [,768 267,056 255,639 95.3% Foster Care Grand Total 20 3.786 690,831 2,279 335,833 60.2% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 2'3 BMS 57 Case Manager 1 Clinical Supervisor 1 Therapist 39 D0 1 6 Youth Care Specialist 1 MST Supervisor 7 Total Staff Reviewed 136 CONFIDENTIAL Page 275 A A State of New Mexico II I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report Billing Systems Audit System Overview TeamBuilders uses EMR Bear as their Electronic Health Record and Practima as their billing system. They interface with Optum Netwerkes to submit their bills for processing and payment. department at supports [8 different sites. There is one person who is in charge of the EMR Bear implementation and he is an expert who handles upgrades and usage as his full time job. There is one person who is in charge of the Practima billing system and handles upgrades and issues as his full time job. EMR Bear is a product that was designed by a Behavioral Health professional. It does not have a very large footprint and it is very popular among the staff members of TeamBuilders. They are able to ef?ciently use it to create their case ?les for patient treatment. TeamBuilders spent a 2 year IT investment in another product that turned out to not be reliable and interfered with staff members performing their duties of recording patient treatment. TeamBuilders concluded that it was better to switch back to EMR Bear which does not do everything they wish it did, but is, in their opinion, reliable. The Practima billing system is used by less than 10 providers in the NM area. The product is supported full time by the creator of the Practima billing system. Practima has basic checks for coding inconsistencies. It also is able to generate and audit trail. However it is not tied to the Optum Netwerkes portal which is a common theme at all providers audited. There is a handoff between the intake, eligibility, EHR, billing system, and Optum. At any one of these points errors could be introduced even with the human double checking processes that TeamBuilders has instituted. TeamBuilders also has an intake and eligibility system. They have a fully documented training system for all levels of staff and standard treatment paths that the clinicians will face. At every step of the intake thru to the billing process, every step is double checked for accuracy. IT Contacts and roles CONFIDENTIAL Page 276 as f?A. as CONSLII llN(. (aliOLil? A State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Ill Application Controls - System Administration and Segregation of Duties The EHR manager is able to set login privileges for staff members to restrict access to patient?s information. The billing manager is able to set login privileges for staff members to appropriately restrict access to parts of the Practima system. and Weaknesses EHR system that they use to record and track clinical records Provide extensive training for every type of employee and diagnosis. Have initial training and training updates. Each step of the billing process from intake to submission is double checked Disaster recovery plan in place Strong eligibility checking process, training and system Strongly documented intake process for new patients Strongly documented process for submitting billing claims in batch process on regular basis to avoid duplicate billing TeamBuilders has invested in EHR systems and put out an RFP for bid a couple of years ago. TeamBuilders appears to keep abreast of new developments in the EH Space. An intemal audit person monitors billing trends by region, diagnosis and providers to identify inef?ciencies or outliers that could be fraudulent. Weaknesses: The point of entry to Optum Netwerkes provides the ability to change any billing from what the clinician entered. EMR Bear is not con?gured to easily provide an audit trail of the events of an encounter There is no direct connection between the EHR system and the billing system which could lead to human error in transcribing Did not have a thorough termination plan for employees and their computer system access privileges There is no complete audit trail of the entire clinical and billing transaction that is guaranteed to correspond to what is billed to Medicaid CONFIDENTIAL Page 277 2% a A Statepf New MEXICO I I Human Serwces Department Behavioral Health Provider Audits PUBLIC CONSULHNC Final Report GROUP Recommendations 0 Develop appropriate accounting controls for charge entry/billing in Optum Portal and Optum Netwerkes. CONFIDENTIAL Page 278 A A A State of New Mexico I I Human Services Department Behavioral Health Provider Audits CONSUI IINL Final Report L.R0tll' Enterprise Audit Provider Speci?c Methodology In conducting the standard enterprise review of TeamBuilders Counseling Services (TB), an extraordinary number of unusual ?nancial relationships and related party transactions were discovered. Accordingly, PCG researched the organization?s ?nances as far back as possible (to 2003), reviewed ownership of properties and researched a number of limited liability companies owning properties that TB rents. Most of these companies are owned by TB executives and their families. PCG also looked at other non-pro?t providers that had linkages to TB and organizations associated with or compensating these executives. Finally, any ?nancial transactions that appeared unusual were examined. For example, a construction contract with unusually bene?cial terms to the contractor prompted contact with the local building department, through which PCG was able to trace the construction company back to an address in Texas owned by the TB CEO and his brother. Audit Observations Tcambuilders has an excessive number of related party transactions for a non-pro?t and a substantial portion of the organization?s funds are being used to bene?t the executive team, their families, or companies closely held by these same parties. It is unusual that so many of these relationships exist in a 501 (3) organization, which is a special status granted by the IRS with signi?cant regulations to insure that these kinds of charities earn a public trust. In granting this special status, the IRS prohibits inurement; meaning that the assets or income of a non-pro?t organization cannot be used to bene?t an individual who has a close relationship with the organization or is able to exercise control over the organization. This prohibition is found in the language of lntemal Revenue Code 501 (3): section 501(c)(3) organization must not be organized or operated for the bene?t of private interests, such as the creator or the creator's family, shareholders of the organization, other designated individuals, or persons controlled directly or indirectly by such private interests. No part of the net earnings of a section 501(c)(3) organization may inure to the bene?t of any private shareholder or individual.? CONFIDENTIAL Page 279 ?g A State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits PUBLIC CONSLILIINC Final Report Key Staff Gay Wellborn Director Robert Pacheco Director Carlos Romero Director Jim Hilber Director Emmett Breen Director Charlie Sandoval Director Jacob Caldwell Director Shannon reedle President Lorraine Freedle Vice President Ben Lucas CF 0 Sun Vega C00 William Johnson Jim Heneghan Financial Relationships Com Type of Company Description Plain View Properties, LLC Limited liability corporation This company leases real exempt estate to TeamBuilders Full Circle Holdings, LLC Limited liability corporation This company leases real exempt estate to TeamBuilders Yellow Brick Properties, LLC Limited liability corporation This company leases real exempt estate to TeamBuilders Oso Doso Properties, LLC Limited liability corporation This company leases real exempt estate to TeamBuilders Zia Behavioral Health Domestic Professional Providers of behavioral health Corporation services Community Wellness Center 50l(c)(3) This organization addresses challenges of unintended teen pregnancies in Taos County Partners in Wellness 501(c)(3) This organization networks administrative and behavioral health services CONFIDENTIAL Page 280 441% State of New Mexico II I Human Services Department Behavioral Health Provider Audits Final Report (.Rour Pathways Youth Family This organization provides Services, Texas social services for Texas children and families Pathways Inc, New Mexico 501(c)(3) This organization provides case management, social intervention, and substance abuse counseling Habilitative Homes, Texas 501(c)(3) This organization is held by Pathways, TX and provides rehabilitative homes in Texas Davidson, Freedle, Espenhover, Overby, Kerrville, Texas Domestic Professional Corporation Providers of ?nancial, accounting, and tax services CONFIDENTIAL Page 281 0 r-?K 22% ll PUBLIC CONSULTING GROUP Summary of Findings and Recommendations Findings Leases paid to limited liability companies owned by TeamBuilders? CEO and family: 2012- $1,217,416 2011 $910,170 2010- $685,482 2009- $551,030 2008- $618,516 2007? $446,156 2006 - 97,046 These payments total $3,308,400 through 201] with additional commitments through 2021 of an estimated $10,682,731. State of New Mexico Human Services Department Behavioral Health Provider Audits inai Report cmlations Payments from the related party LLCs should be audited for con?ict of interest. Additional leasehold and other capital purchases made by TeamBuilders should be reviewed to determine if additional bene?ts have accrued to the owners of these properties in the form of capital improvements. 0 In 2007, TeamBuilders entered into a ten year lease agreement with Plainview Properties, LLC for property to be built at 121 Towngate in Clovis, NM. TeamBuilders agreed to pay fees of: during the construction process 100% of the architect?s fees of $50,000 in leasehold improvements in security deposit for this location. Rental payments for the ten year lease total $1,979,928. Plainview Properties, LLC is owned in whole or in part Of?cers and directors of TeamBuilders should be evaluated for con?ict of interest, inurement, excess bene?t, and/or private bene?t based upon these transactions. Plainview Properties, LLC should be evaluated to determine if it is a ?disquali?ed person" under excess bene?t regulations. RCH 1nc., the contractor that built the Clovis, NM property should be evaluated to determine if it is a "disquali?ed person" under excess bene?t regulations. CONFIDENTIAL Page 282 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Hill 1111 PUBLIC ONSLILI INC by the CEO and his family. According to building permits ?led with the City of Clovis, NM this facility was constructed by Inc. of 222 Sidney Baker Suite 635, Kerrville, TX - a property owned by the CEO and/or his brother, Patrick Freedle. The address is the same as Patrick Freedle?s accounting ?rm Davidson, Freedle, Espenhover Overby. The contractor?s phone is listed as 830-257-3951 which is TeamBuilders? headquarters in Santa Fe. Estimated construction costs paid were TeamBuilders leases property in Clayton, NM from Plainview Properties LLC. This NM Corporation 2740801) is classi?ed as exempt and listed as a related party. TeamBuilders? CEO is listed as both organizer of the company and its agent. Lease payments from 2006 to 2016 are estimated at Of?cers should be evaluated for con?ict of interest. inurement, excess bene?t, and/or private benefit based upon these transactions. Plainview Properties, LLC should be evaluated to determine if it is a ?disquali?ed person" under excess bene?t regulations. TeamBuilders leases property in Santa Fe, NM from Yellow Brick Preperties, LLC. This NM Corporation 2671733) is classi?ed as exempt and listed as a related party. TeamBuilders? CEO is listed as organizer of the company and TeamBuilder?s COO, Sun Vega, is listed as its agent. TeamBuilders spent on leasehold improvements and a security deposit of $56,460. Lease payments from 2007 to 2017 are estimated at $4,012,900. Of?cers should be evaluated for con?ict of interest. inurement, excess bene?t, and/or private bene?t based upon these transactions. Yellow Brick Properties, LLC should be evaluated to determine if it is a "disquali?ed person" under excess bene?t regulations. CONFIDENTIAL Page 283 7??ng HI PUBLIC CONSUUINC State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report (.ROUP TeamBuilders leases property in Tucumcari, NM from Full Circle Holdings, LLC. This NM Corporation 2671725) is classi?ed as exempt and listed as a related party. TeamBuilders? CEO is listed as both organizer of the company and its agent. Lease payments from 2007 to 2017 are estimated at $1,060,795. Of?cers should be evaluated for con?ict of interest, inurement, excess bene?t. and/or private bene?t based upon these transactions. Full Circle Holdings, LC should be evaluated to determine if it is a ?disquali?ed person? under excess bene?t regulations. TeamBuilders leases property in Riudoso, NM from 050 Doso Properties, LLC. In 2011 TeamBuilders? C00, Sun Vega, ?led articles of incorporation in NM as agent and organizer of the corporation. Oso Doso Properties, LLC. 4428934) is classi?ed as exempt and listed as a related party. Teambuilders has lease commitments of approximately $1,575,359 from 2011 to 2021 for use of this property. The property was purchased by this related organization for in 2011. Several other businesses list addresses at his location and may be paying rent as well. TeamBuilders had suf?cient capital to purchase this property outright in 2011 and would have saved $1,253,359 in lease payments had it been purchased for If there are other tenants in the building, TeamBuilders could have received the bene?t of unrelated business income. In light of the decision made by of?cers to purchase the building for themselves and lease it to Teambuilders. of?cers and trustees should be evaluated for con?ict of interest. inurement. excess bene?t. and/or private bene?t. Oso Doso Properties, LLC should be evaluated to determine if it is a ?disquali?ed person" under excess bene?t regulations. TeamBuilders leases property in Las Vegas, NM from Yellow Brick Properties, LLC. This NM Corporation 2671733) is classi?ed as exempt and listed as a related party. Of?cers should be evaluated for con?ict of interest, inurement, excess bene?t, and/or private bene?t based upon these transactions. CONFIDENTIAL Page 284 A?r?x State of New Mexico Human Services Department as I I Behavioral Health ProviderAudits PUBLIC CONSULI INC Final Report TeamBuilders? CEO is listed as organizer of the company and a Yellow Brick Properties, LLC should be evaluated to TeamBuilders? COO, Sun Vega, is listed as its agent. Lease detemiine if it is a ?disqualified person" under excess payments from 2009 to 2019 are estimated at benefit regulations. In 2011, TeamBuilders entered into a related party lease with 0 Of?cers should be evaluated for conflict of interest. Cielo Azul Holding, LLC for a facility in Taos, NM for 5 years inurement, excess bene?t, andr'or private bene?t based beginning 1/ 1/201 and paying annual rent of per annum. upon these transactions. Cielo Azul Holding is owned in whole or in part by TB CEO and his family. Of?cer?s compensation. In FY12, Shannon Freedle was granted 0 Total compensation and related income should be a raise of 71%, bringing his compensation as CEO to examined for all of?cers of TeamBuilders. Lorraine Freedle was granted a raise of 46%, bringing her compensation as VP to Combined with estimated income from related transactions, this family?s income from the non-pro?t is estimated as high as per year. Shannon Freedle also serves as CEO of The Community Wellness Center and received compensation in FY10 of $12,913. Unrelated of?cers. 0 Total compensation and related income should be 0 Ben Lucas, TeamBuilders? CFO, serves as manager at examined for all of?cers ofTeamBuilders. two other LLCs - Quiet Oasis, a Texas corporation and Other organizations should be examined to determine if Kerrvillc 415, also a Texas Company at the same address they meet the test for disquali?ed persons. as Davidson, Freedle, etc., TeamBuilders? tax advisors and brother of the CEO. 0 Mr. Lucas serves as CFO for Community Wellness Center and received compensation of in FY10. ln CONFIDENTIAL Page 285 4% Hill ?g PUBLIC CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 2012, Mr. Lucas received compensation from Pathways, TX of and from Pathways, NM of substantially increasing his compensation. Ms. Sun Vega serves as COO for Community Wellness Center and has received similar compensation to Mr. Lucas. In 2012, Ms. Vega received compensation from Pathways, TX of 37K and from Pathways, NM of substantially increasing her compensation. Ms. Vega, TeamBuilders? COO has ?led as agent for several other exempt NM corporations: 050 Doso LLC (4428934) 0 Yellow Brick Properties, LLC 267l733) 0 Highland Sipapu LLC 4660625) All of these corporations list TeamBuilders? Headquarters, 2504 Camino Entrada, Santa Fe, NM as headquarters. Ms. Vega also serves as COO of the Community Wellness Center and receives compensation of in FY10. In 2012, she received compensation from Pathways, TX and Pathways, NM. CONFIDENTIAL Page 286 A State of New Mexico I Human Services Department ii i i Behavioral Health Provider Audits PUBLIC lMCi Final Report Pathways, Inc. Texas. 0 These transactions should be audited to determine if excess 0 At 12/31/11, TeamBuilders lent Pathways, Inc. of Texas bene?t in the form of rent has inured to the CEO, CFO, in cash and guaranteed a loan of and any other owners of Kerrville 415, LLC as a result of TeamBuilders now has a controlling interest in the loaning and risking TeamBuilders? assets. organization. Shannon Freedle became CEO/President and Ben Lucas became CFO. I Also in 20] l, Pathways TX became a tenant of property at 222 Sidney Baker, Kerrville, TX paying in annual lease payments. The property is owned by Kerrville 415, LLC. Shannon Freedle, Ben Lucas, and others have an interest in Kerrville 4l5. This building is also the site of Freedle?s brother?s CPA ?rm. 0 In 2011, Habilitative Homes of Texas was acquired and became a tenant of a related party paying rent of$42K per annum. Miscellaneous: 0 Each of these transactions was identi?ed as unusual from 0 In 2010 TeamBuilders entered into a ?business ?nancial statements, tax returns, or other sources. While combination? with True North Consulting. the amounts noted are relatively small, it is recommended 0 [n two grants were given to Golden that they be reviewed ?nancial audit IS Retreat, owned and Operated by an employee of TeamBuilders, Ted Wiard and governed by a member of TeamBuilders? Board, Jacob Caldwell. 0 From 2003 to 2005, TeamBuilders paid an of?cer approximately per year for of?ce rental in Colorado. CONFIDENTIAL Page 287 PUBLIC INC GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 2011 investment is noted in Sendero Ranch. This is an unusual investment for a non-pro?t. 0 Highland Sipapu LLC 4660625) was organized by Sun Vega, C00 and lists TeamBuilders? Santa Fe headquarters as its address. However, no further information was available. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements Provider Organizational Chart Form 990 (Nonpro?t ?ling) Third-party Contracts 2003 - 2012 Current 2003 - 2012 CONFIDENTIAL Page 288 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC COONSLILI Final Report C111 111? 111111111100 51100: 2003 200-1 2005 2006 21108 2011?) 2010 Assets Cash Investments AIR AIR employees Related party receivable Property Equipment 178,882 201.342 5 369.457 Promised use of factitiesfcm'rcnt Promised use of facmiesllong term Land Held for future expansion Other Assets Goodwill Long term security deposns Total Assets 8 1.331.287 1.671.667 1.601.883 2.338.086 2.850.303 442.403 4 1 5.863 235.698 1 .7 1 0 325.122 510.581 520.623 2.200 1 88.546 540.8 1 0 428,369 9, 150 464.447 686.633 533.948 3,83 1 353.627 820.732 648.097 2.82.7 31.782 5.777 715.830 1,213,994 1.416.169 1.369.695 24,828 5 24,828 24,828 6 0.05 1.342.873 3.579 3.433.672 5.243.390 437.164 1.084.996 1.091.712 1.948.947 3.555.038 5 8.714 5 10.30] 3.540.452 2.640.064 9.145 3 7.925 3.787.525 Ma?a!? ?"1me MWHM 5,777 7,471 1.746.059 21.725 452.275 24.828 96.209 54.696 2 1 ,2 19 71.38] 46.553 01.725 54.696 54.696 54.696 126.508 95.484 45.000 100.175 4.912.705 54.696 2.035 54.696 54.696 57,103 10.855 5 54.696 5 54.696 264.245 220.461 360.161 63.000 63.000 63.000 0909mm?! 93 100.175 1 11.745 193.794 6.921.877 10,512,791 14.521.800 Liab?ities Accounts Payable Accrued Expenses Notes payable Line ofCredil TotalLinbilitics 198.861 175.438 242,359 321,481 545.532 1.011.821 992.026 1.324.835 1 1.738 143.050 44.073 69 21.121 139,276 15.041 (A 46.244 14.806 182.059 293.859 14.056 12.816 (A 74.516 460.144 10.872 IA 386.631 615.712 9.478 (A -335 9 293.955 750.958 1 .025 .332 7.549 5.548 687.967 1.433.503 3.328 530.000 2.654.798 (A 111151191191!) NelAssets 1.132.426 1.496.229 1.359.524 2.016.605 2.304.771 3.900.884 5.929.851 Total Liabilities and NetAssets 1.331.287 1.671.667 1.601.883 2.338.086 2.850.303 4.912.705 6.921.877 V1 9.187.956 10.512.791 VJ 11.867.002 14.521.800 (I) CONFIDENTIAL Page 289 r?s IHII PUBLIC CONSULTING GROUP [monu- Statement Revenue Program 81 Service Fees Contributions Investment Income In-l-tind contributions Special events Other revenue Net asset release Total Revenues and Suppo Expenses Program Services Supporting Services Total Expenses 21111.1 2401.096 2.831 2.403.927 1.683.763 598.062 2.23 1.825 1nhcrent contribution from Pathways TX Change in Net Assets Net Assets. beginning ofyi Net Assets. end ofyenr 122102 1.010.264 1.132.366 2.982.342 1 09.682 3.092.024 2.412.454 315.707 2.728.161 363.863 1.132.366 1.496.229 111115 3.45l.9l9 35.560 3.487.479 3.166.203 457.981 3.624. 1 84 (136.705) 1.496.229 1.359.524 3111111 6.077.164 121.037 65.649 3,723 6.267.573 4.809.657 800.835 5.6 I 0.492 657.081 1.359.524 2.016.605 211117 8.129.781 85.720 1 56.737 1 .988 8.374.226 6.601 . I 67 1.4 84.893 8.086.060 288.166 2.016.605 2.533.734 2008 13.184.064 75.491 (87.761) 53,159 13.224.953 10,518.971 1.338.832 I 1.857.803 1.367.150 2.533.734 3.900.884 17.236353 85.478 1 I61.322) 21.535 17.182.044 13377.23] 1.775.846 15. I 53.077 1028.967 3.900.884 5.929.851 State of New Mexico Human Services Depanment Behavioral Health Provider Audits Final Report I II 21.681.771 81.008 27.778 101.898 21.892.455 I 6.3 80.905 2.253.445 I 8.634.350 3.258.105 5.929.851 9.187.956 24.101894 57.824 485.438 65.878 1 14.905 305.32 1 25,137,260 I 9.91 0.897 3.349.274 23,260. I 71 80 I .957 2.679.046 9.1 87.956 1 1.867.002 CONFIDENTIAL Page 290 PUBLIC CONSLILI GROUP Excess Benefits Table This table estimates the total bene?t per year paid to the CEO and his family. 0 Columns 1 and 2 represent direct compensation paid to Dr. and Mr. Freedle. 0 Column 3 represents 40% of payments made to a behavioral health organization 40% owned by the CEO and his family. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 Column 4 shows lease payments made to holding companies owned in full or in part by the CEO, his family, and other of?cers of TeamBuilders.* 0 Column 5 represents payments made to the company at the same address. *Because details on the extent of of?cer ownership in the limited liability holding companies is not fully disc some unrelated parties receive a portion of this rental income. 20l2 20ll 2010 2009 2008 2007 2006 2005 2004 2003 Total Shannon li'reedlc 357,389 l47,710 l5 L405 124,98l l01,398 l01,263 93,417 84,269 l,265,l 14 Lorraine l-?reeillc Dam Not Available 299.1 59 139,309 143,407 l29,32l 1 20,026 9 ,5 99 79,092 69,72 69,22 I 1,140,855 31,000 401,000 240,800 201,600 82,800 207,000 84,000 1,248,200 brother 9 BB @3905 1,2l 7,416 9 0,l 70 685,482 551,030 6 8,5 16 446,156 97,046 3,308,400 69 69 Related 1m I?lle 1 l7,529 24.084 I 1,755 93 ,000 9,000 9,300 264,668 Accounting: Firmf'l?cuis 25,000 02,000 54,000 36,000 35.000 35,000 24,000 20,000 24,000 13 .000 343,000 Texas accounting ?rm as well as lease payments to a holding losed, it is possible that Total 1,342,416 l,699,7 8 1,545,030 I, 46,726 l.121,l73 787,264 52 ,043 377,355 196, 38 75,790 7,570,237 CONFIDENTIAL Page 29l C) A g: A State of New Mexico Human Services Department ii i Behavioral Health Provider Audits PUBLIC CONSLILTI NC Final Report GROUP Rental Income This table portrays the signi?cant, cumulative impact of multi-year leases between Teambuilders and multiple related parties in the form of limited liability corporations organized and owned by TeamBuilders? officers (CEO, CFO, C00, etc.) and members of their families. These commercial property leases with multiple holding companies typically span ten years. FCC has estimated the established duration of these commitments without assuming lease renewal at the end of ten years, although renewal is likely. It is noteworthy that while the organization invested in land for expansion in Quay County with the intention of building a facility, it continues to hold this land and instead entered into leases and construction contracts with related party holding companies to develop property that it would never own. PCG considers this signi?cant because more than per year in Teambuilders assets is diverted to its officers and their families. While prosperous from its state contracts. Teambuilders does not own a single piece of real estate that it occupies. Teambuilders has essentially built a sizeable real estate portfolio for its of?cers. CONFIDENTIAL Page 292 State of New Mexico Human Services Department Behavioral Health Provider Audits l?lJlil 1L ONSLILI Final Report (.110th Excess Bene?ts 2006 2007 21108 200?) 2010 Santa Fe Clayton 12.600 Clovis Ruidoso Las Vegas 46,000 47.712 'l?ucumcari #1 84,446 84.446 84,446 84.446 84.446 Tucumcari#2 10.350 10,670 11.000 11.124 Kem'illeIX San Antonio,TX Taos,NM Totals '5 97,046 5 446,156 3 618,516 5 551,030 685,482 '8 910,170 69 338,760 1 2.600 338,000 219.000 351.000 12.600 3 12.600 12.600 172.800 1 77.984 1 78.600 371 .830 1 2.600 193.640 123.000 135.000 49.000 50.470 361,000 84,446 84446 1 2.600 1 88.000 382.985 1 2.600 199.449 394.474 12.600 205.433 139.050 143.222 51,984 53.544 84.446 5 84.446 (2.360 12.73 1 85.933 88.51 1 43.260 44.558 238.960 246.129 1,251,027 1,285,647 11.124 12.000 81,000 83.430 42.000 232.000 1 ,21 7,41 6 Total as 2.757.049 1 13,400 I ,3 15.906 540.272 298.710 760.014 91.359 338.874 129.81 8 71 7.089 7,062,490 Santa Fe Clayton Clovis Ruidoso Las Vegas Tucumcari #1 406,309 1 2,600 2 1 1 .596 418.498 431.053 12,600 5 217,944 147.518 5 151.944 55.150 56,804 84,446 84,446 5 69 224,482 156,502 161.197 166.033 8 171.014 176.144 58,509 60.264 62.072 99 (A ?6 Tucumcari #2 13,113 13,506 KemtilchX 91.166 93,901 San Antonio, T): 45,895 47,271 Taos. NM 253.513 261.1 18 Totals 5 1,321,305 1,358,033 13,91 1 96,7 1 8 48.690 268,952 1 ,298,81 6 99.620 50. 1 50 277.020 648,2 5 1 102.608 51.655 285.33 1 667,699 105,687 108.857 53.204 54.800 56.444 293,891 302.707 5 3 1 .789 623,796 5 368,233 1.438999% 93999909 CONFIDENTIAL Page 293 9 3 A A A State of New Mexico 0 Human Services Department Behavioral Health Provider Audits PUBLIC CONSULIINC Final Report (.Itour Compensation Nun tuxahlc Employee ()thcr 'l?utnl Bone his 2012 estimated use previous year's compensation 2011 Shaman Freedle 236,284 105,365 15,740 357,389 Lorraine Freedle 189,153 95,596 3 14,410 299,159 Adrian Chavarria - Ben Lucas 102,889 16,797 119,686 Sun Vega 5 105,837 19,344 125,181 Wiliam Johnson, MD 8 181,674 13,744 13,764 209,182 Jim Heneghan, MD 3 252,552 252,552 2010 Shannon Freedle 135,587 132,419 12,123 280,129 Lorraine Freedle 127,703 99,694 11,606 239,003 Adrian Chavarria 60,505 8 12,1 15 72,620 Ben Lucas 13 79,686 20,912 100,598 0 Sun Vega 62,699 3 23,051 85,750 2009 Shannon Freedle 133,937 185,468 17,468 336,873 Lorraine Freedle 125,451 181,233 17,956 324,640 Adrian Chavarria 60,213 9,971 70,184 Ben Lucas 3 73,999 1,998 75,997 Sun Vega 3 63,466 21,101 84,567 Comp from related 2008 Shannon reedie 112,600 76,000"l 12,381 200,981 Lorraine Freedle 116,814 8 12,507 196,457 Ben Lucas 52,999 7,781 8 60,780 Sun Vega 8 67,691 8,471 76,162 Paul McQuaid 53,243 4,762 58,005 Theodore Wiard 45,547 5 5,012 5 50,559 Adrian Chavarria 8 52,999 10,593 63,592 CONFIDENTIAL Page 294 711? I A CONSULI .llOtll? [Employee Compensation Non taxable State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Total Bene?ts 2007 Shannon Freedle 92,804 61,333? 10,478 164,615 Lorraine Freedle 109,108 10,918 3 189,251 Adrian Chavarria 42,296 3 8,914 51,210 Ben Lucas 3 63,395 2,318 65,713 Sun Vega - 2006 Shannon Freedle 98,445 2,953 101,398 Lorraine Freedle 88,931 2,668 91,599 Adrian Chavarria 40,188 1,206 41,394 Ben Lucas 61,051 1,832 62,883 5 2005 Shannon Freedle 101,263 101,263 Lorraine Freedle 3 79,092 79,092 Adrian Chavarria 37,885 37,885 Ben Lucas 61,276 61,276 2004 Shannon reedle 93,417 93,417 Lorraine Freedle 69.721 69,721 Adrian Chavarria 24,039 24,039 Ben Lucas 42,566 42,566 2003 Shannon Freedle 84,269 84,269 Lorraine Freed1e 69,221 69,221 Adrian Chavarria 41 ,807 41,807 Ben Lucas 14,500 14,500 CONFIDENTIAL Page 295 Valencia Counseling Services Inc. Clinical Narrative IT Narrative Enterprise Narrative AA PUBLIC CONSULTING GROUP pcghealth.com A State of New Mexico . I I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC Final Report VALENCIA COUNSELING SERVICES BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review March 6 14, 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $4,128,958 Actual Longitudinal Overpayments $64,907 Total Overpayments I 93,865 Scorecard results are as follows: Random Sample Compliance Rate Longitudinal Compliance Rate Prowler Seamed"! Signi?cant A ?Wm? This scorecard result translates to the following Risk Tier: 2 Signi?cant volume Of ?ndings that 0 Provide trainings and clinical include missing documents assistance as needed. 0 Potentially embed clinical management CONFIDENTIAL Page 314 as: A A State of New Mexico I Human Services Department I Behavioral Health Provider Audits l?UliLlC 83mg? IINC. Final Report to improve processes. Provider Overview Valencia Mental Health Services provides behavioral health services in four counties in New Mexico; Sandoval, Bemalillo, Valencia, and Cibola. Within these locations, Valencia delivers behavioral health services including rehabilitation, childcare food program services, DWI school services and housing services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 5 Claims Paid FY12 5 Claims Paid Audit Period BHSD 1,058,085 4,344,262 CYFD 67 67 Medicaid FFS 47,705 236,472 Medicaid MCO 1,309,341 5,055,694 NMCD 5,497 5,497 1 Other 0 0 Grand Total 2,420,695 9,641,993 Audit Team Observations - On Wednesday, March 4th, PCG held an entrance conference with Valencia Counseling Services_ upon arriving onsite, explaining the reason we were there, what we needed to review, and the anticipated sequence of events, in addition to answering any questions. 0 Case ?les began to arrive within an hour of the conclusion of the entrance conference. Valencia does utilize the Anasazi system, however, hard copy files were provided to PCG. 0 All case and staff ?les were provided in paper format and the PCG audit team manually pulled the necessary documents from the case ?les. 0 The majority of consumer and staff ?les were provided over 14 business days. A few of the requested documents were provided electronically later as they were offsite. CONFIDENTIAL Page 3 15 ll PUBLIC CONSLILI GROUP 0 met with Valencia IT systems staff to review their billing and clinical systems, including inputs, outputs and audit trails. Random Date of Service Claim Review State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Valencia staff was slow in responding to audit team requests for clari?cation or additional information. Clinical Reviewers noted the following general ?ndings: 0 Safety Assessments were not completed or updated for consumers who were assessed to have current or past suicidal ideations (SI), homicidal ideations (H1), self harm or domestic violence issues. Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were incomplete of critical information for the date of service under review. Treatment plans were missing, dif?cult to interpret and track progress, and/or not individualized per consumer. Progress Notes/Recipient Documents were missing, incomplete, and insuf?cient of necessary information. PCG reviewed one hundred and ?fty (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 random audit sample and the resulting ?ndings: Procedure ?flue Claim 5 ?flue Claims Program Description Claims Claims Claims Code . . Failed Renewed Renewed . Failed Failed Diagnostic I - 90791 Evaluation 1 87 0 0 0.0 A: 90801 Diagnostic 8 654 0 0 0.0% Evaluatlon 90804 Outpatient?2060 minutes 7 307 0 0 0.0% 90806 Outpatient?4560 minutes 39 2,731 0 0 0.0% 90808 Outpatient?4540 minutes 1 79 0 0 0.0% 90847 Family Therapy 1 78 0 0 0.0% CONFIDENTIAL Page 316 State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC IINC. Final Report 90853 Group Therapy 4 147 0 0 0.0% 90862 Medication Management I4 944 0 0 0.0% H0015 Intensive Outpatient Program 3 397 0 0 0.0% Crisis Intervention Services 4 222 0 0.0% H2015 HO, HM, 22 1.354 20 1,286 90.9% H2017 Rehabilitation 24 4,0 8 23 3,926 95 Behavioral Health Treatment T1007 Plan Update 22 2,536 17 1,975 77.3% Grand 150 Total ?5 0 0 Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 317 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report . Ps chi Recrpient Assessment Treatment Service Consent Progress Billing Staffing Pharma Other Comments DOS Screening Plan Delivery Nags Forms Consumer diagnosis does not meet SMI de?nition. No progress note was located to support services. No progress note was located to support services. Treatment plan does not provide specific support services needed. Progress note states 'talking to public servants? unable to document any service was delivered to consumer. Progress note H2015 Pass Pass Faii Fail NA Fail NA NA NA states 'taiking to public seerment any service H2015 Fail Fail Fail Fail NA Fail NA NA NA was delivered to consumer. missing credentials per staff list No specific interventions were documented in progress note. The progress note does not support the units billed. H2015 I Pass Pass Pass Fail NA Pass NA NA NA The progress note does not support the units billed. H2015 Pass Pass Pass Fail NA Pass NA NA NA No assessment or treatment plan were submitted for review. Dispensing meds is out of scope for CSW. Dispensing meds is H2015 Fail Fail Fail Fail NA Fail NA NA NA out of scope for CSW. No safety assessment. This a dispensing medications. Dispensing meds is out of scope for CSW. No assessment or treatment plan were submitted for rein'ew. No documentation of speci?c intervention. No safety assessment. Originally assessed in 2008. consumer continues to receive H2015 3_ Fail Pass Pass Fail NA Pass NA NA NA 6088 for same objectives and goals that were set in 2008. Cannot support medical necessity of units billed. The assessment did not include a 5 access diagnosis. therefore. unable to determine if consumer meets SMI requirement. The H2015 Fail Fail Pass Fail NA Pass NA NA NA progress note documents consumer picking up medication samples. Safety concern that CSW is eptaining meds to consumer. No progress noted. Documentation does not support H2015 Fail Fail Pass Fail NA Pass NA NA NA CONFIDENTIAL Page 3 l8 A State of New Mexico I Human Services Department BL Behavioral Health Provider Audits IC INC Final Report CCSS intervention. There is not 5 axis dx in the assessment Historically consumer has had suicide attempts and abused and has anger issues. She is just out of prison. Assessment does not document if she currently has any thoughts of self harm or harm to others. No documentation of safety plan if or HI 0088 is not one of the interventions documented in the treatment plan. H2015 3? Pass Pass Fail Fail NA Fall NA NA NA Different provider than server. Quali?cations were not submitted for this CSW. Quali?cations were not submitted for this CSW. CSW work dispenses meds to consumers. Progress note 5 atrent was in to pick up samples of H2015 Fail Fail Pass Pass NA Fail NA NA NA medication. assisted her with prepackaged samples Quali?cations were not submitted for- Out of scope for CSW. H2015 Pass Pass Pass Pass NA Fail NA NA NA .. . Ps chi Proc Recrprent Assessment Treatment Servrce Consent Progress Billing Staffing Pharma Other Comments Notes Forms Code DOS {Screening Plan Delivery . . A comprehensive assessment was not submitted. Quali?cations i-I2015 Faii Pass Pass Pass NA Fail NA NA NA were note submitted. A comprehensive assessment was not I. submitted. - 3 . No safety assessment. Quali?cation review fo-_ 112015 Pass Pas Pa . 8 53 Fall NA Fa? NA NA NA revealed she did not meet requirements for lnterven on is not explained. Units billed are not supported by H2015 5? Pass Pass Pass Fail NA Fail NA NA NA documentation, quali?cations were not submitted for this CSW. - Quati?cations were not submitted for this CSW. . . No safety assessment Practitioner is not on staff roster. No H2015 - Pass - i all ass Fail NA Fail NA NA NA "eminent plan summed for review. . Documentation was not submitted for review. No treatment plan - in ass Pass NA Pass NA NA NA Assessment. Diagnosis were submitted. Unable to support CONFIDENTIAL Page 319 PU BUC CONSUL l'lNC GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report consumer is eiigibte for C655. No treatment plan. Assessment, Diagnon were submitted. t'l2015 Fail Fail Pass Fail NA Fail NA NA NA Documentation was not submitted for review. No treatment ptan. Assessment, Diagnosis were submitted. Unabie to support consumer is eligible for CCSS. No safety assessment. No quali?cations were submitted for this practitioner. No treatment plan, Assessment. Diagnosis were submitted. H2015 Pass Pass Pass Fail NA Fail NA NA NA No safety assessment. Documentation does not support units billed. only intervention identi?ed 'lD Triggers? also 1 unit for team meeting. Quaiitications were not submitted tor- - bitted for 9 units, for 1 unit, qualifications issues with both. H2015 Pass Pass Pass Fail NA Fail NA NA NA No safety assessment. CSW worke-depTeW mods to consumers. Progress note states 'Patient was in to pick up samples of medication. CSW is not quali?ed to dispense meds. i't2015 Pass Pass Pass Pass Fail NA NA CSW does not meet quali?cation requirements. H2017 Pass Fail Fail Fail Fail Fail NA NA NA There is no progress note for this date of service. Service is not supported. Onty PSR Supervisor is H2017 Fail Fail Pass Pass Pass Pass NA NA Consumer Diagnosis Update dated 121312012 documents SMI however practitioner did not submit quali?cations. in PSR since 2005, long length of stay. Unable to vatidate licensed ciinicians quaiitications. PSR intervention is non speci?c as to goat of intervention. H2017 Fail Fail Fail Fail Fail Fail NA NA NA No assessment was submitted with 5 axis diagnosis to substantiate if consumer is appropriate for PSR. No progress note for PSR. cannot support PSR services were provided on this date. No progress note for PSR. cannot support PSR services were provided on this date. No progress note for PSR, cannot support PSR services were provided on this date. no progress CONFIDENTIAL Page 320 CONSULI State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Recipient Assessment DOS lScreening H2017 Fail Treatment Plan Pass note for PSR. cannot support PSR services were provided on this date. No progress note for PSR, Cannot support PSR services were provided on this date. There is no PSR treatment plan or list of PSR team members. 1 Progress Notes Service Consent Forms er Billing Staffing Pharma Comments ivery No assessent with 5 axis diagnosis was submitted to validate it consumer is appropriate for PSR. The PSR team members are not documented. Pass Pass Pass Fail NA NA NA H2017 j' Fail Fail Assessment mentions possible eligibility for PSR. Treatment Plan contains no PSR goals. No progress note was submitted to support this service. PSR is not part of the treatment plan. Fail Fail Fail Pass NA NA NA H2017 Fail Pass No assessment was submitted for review. Cannot document consumer is appropriate for PSR. Progress note is vague, documents Cit attending a conference No documentation that worker attended. No assessment was submitted for review. Progress note was siined by- - claim billed undo no risk assessment Pass Pass Fail Pass NA NA NA H2017 Pass Fail No treatment plan was submitted for review. there was no progress note submitted for this DOS. There was no progress note submitted for this DOS. There was no progress note submitted for this DOS. There was no progress note submitted for this DOS. There was no progress note submitted for this DOS. No documentation of PSR team. There was no progress note submitted for this DOS. No treatment plan was submitted for review. No treatment plan was submitted for review. Fail Fail Fail Faii NA NA NA H2017 Fail Fail For SMI consumer must be diagnosed within the prior 12 months. A review performed within 12 months of the date at service was not submitted for review. Cannot con?rm consumer is SMI. Clinical assessment is dated 12m2001. There is no Fail Fail Fail Fail NA NA NA CONFIDENTIAL Page 32] A?r?a A State of New Mexrco A I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP progress note for this date of service. Service is not supported. For this date of service. there is no timely documentation of the treatment team members. No safety assessment. A 5 axis dx was not submitted. No team roster. did not meet H2017 Fail Faii Pass Pass Fail Fail NA NA NA qualification requirements per roster review. Quali?cations for this 1 clinician were not submitted. No progress note was submitted for this date of service. Cannot support services. No documentation of members of PSR team. No progress note was submitted for this date of service. Cannot support services. Progress note provided is for 1125(2012 for treatment plan review. . . . PSR is not supported by documentation. No quali?cations for this H2017 Pass Fail Fastaff member per submitted roster. No quali?cations for this staff member per submitted roster. H2017 Pass Fail Fail Fail Fail Fail NA NA NA . . . Recrplent Assessment Treatment Sen/ice Consent - . DOS [Screening Plan Delivery SEES B'llmg Staf?ng Forms comments There is no progress note for this date of service. Service is not supported. There is no progress note for this date of service. Service is not supported. There is no progress note for this date of senrice. Service is not supported. There is no progress note for this date of service. Service is not supported. There is no H2017 Pass Fail Fail Fail Fail Fail NA NA NA progress note for this date of service. Service is not supported. No documentation oi members of treatment team. No note to support services. claim does contain name of quali?ed practitioner. PSR service needs are expressed in same language as seen on other treatment plans. Non speci?c PSR goal. no separate PSR treatment plan. . . A treatment plan was not submitted. A progress note was not I H2017 Pass Fail Fail Fail Fail Fail NA NA NA summed. no Gammonth for services. H2017 A Fail Fail Pass Pass Fail Fail NA NA NA Consumer diagnosed with PTSD, not and SMI dx, does not meet CONFIDENTIAL Page 322 State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC. INC. Final Report eligibility criteria. No team roster. not prope?y quali?ed per reveiw of staff roster?s designated as not properly quali?ed per reveiw of staff roster. H2017 Pass Pass Pass Pass Pass Fail NA NA NA No roster. H2017 Pass Pass Pass Pass Pass Fail NA NA NA No roster. H2017 Pass Pass Pass Pass Pass Fail NA NA NA No roster for team. H2017 Pass Pass Pass Pass Pass Fail NA NA NA No roster. H2017 Pass Fail Fail Fall Fail Pass NA NA NA A progress note for this date of service was not submitted. Missing Document: There is no progress note for this date of Pass Fail Fail Fail Fail Pass NA NA NA service. Service is not supported. Missing Dowment: There is no I progress note for this date of service. Service is not supported. H2017 Pass Fa? Fa? Fa? Fail Fa? NA NA NA There is no progress note for this date of service. Service is not . - supported- No documentation; no progress note for this date of service. A progress note for this DOS was not provided. H2017 Pass Fail Fail Fail Fail Pass NA NA NA H2017 Pass Fail Fail Fail Fail Pass NA NA NA No documentation; no progress note for this date of service. Progress note documents service was Individual Therapy not Treatment Plan review. A treatment plan initiated on this date of T1007 NA Fa? NA NA NA Pass NA NA NA service was not submitted, however treatment plans that were submitted show goals set in March of 2012. . . chi Proc Remprent Assessment Treatment Servrce Consent .. Cede DOS lscreenmg Plan Delivery Billing Sta.frng Forms Pnarma Other Comments T1007 NA Fail NA NA NA Pass NA NA NA Supervisor did not sign. CONFIDENTIAL Page 323 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Till Unable to determine with the limited documents see below. See T1007 NA Fall NA NA Fall below. See below. See below. T1007 NA Fail NA NA NA Pass NA NA NA No consumer signature. No signature page submitted. An updated treatment plan was not submitted. signature page is T1007 NA Fail NA NA NA Pass NA NA NA dated 1/19/2012 but there is not Treatment Plan bearing that date. T1007 NA Fa? NA NA NA Pass NA NA NA Treatment plan dated In August at 2010 was not Treatment plan submitted is for date 5/27/2010. T1007 . NA Fail NA NA NA Fail NA NA NA 71007 - NA Fail NA NA NA Pass NA NA NA No treatment plan was submitted for review. Consumer signed care plan which is electronically dated Pass Pass NA NA NA 11/8/2011. Care plan itself has no updates on 11/8/2011. T1007 NA Fail NA NA NA Pass NA NA NA No consumer signature. T1007 NA Fail NA NA Fail Fail NA NA NA A treatment Plan was not submitted for review. Documentation supports an initial assessment not an update. T1007 NA Fall NA NA NA Pass NA NA NA Lacking in discharge planning. Mental Health Assessment was not submitted for review. T1007 NA Fail NA NA NA Pass NA NA NA Treatment Plan has goals going back to 2006. No documentation of any updates to treatment plan other than date at top of page. According to the progress note, the update occurred 10/13/2010. T1 I 007 A NA Fall NA NA NA Pass NA NA NA the updated treatment plan was not submitted for review. T1007 NA Fa? A NA NA Pass NA NA NA Treatment plan IS dated 12/21/2011, one year AFTER . I this DOS. . No evidence of discharge planning, goals and target behaviors, T1007 NA Fall NA NA NA Pass NA NA NA just to .miew in 90 I I I w. CONFIDENTIAL Page 324 Ai?t 44% A State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report PUBLIC CONSLILI INC T1007 NA Fa? NA NA NA Fail NA NA NA An updated treatment plan was not submdted. the last update was 9/19/2011. CONFIDENTIAL Page 325 A A A f?A? A State of New Mexico I Human Services Department PUBIJL Behavioral Health Provider Audits amour Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that pepulation. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely reflects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ l/2009 1/31/2013 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Valencia Mental Health Services Sample Size 150 Total Paid for Sample $13,554 Sampling Frame Size 108,047 Number of Sample Claims with Overpayments 60 Tentative Overpayment Using Lower Bound of the 90% $4 128 958 Con?dence Interval Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the claims associated with each selected procedure code and recipient which were paid CONFIDENTIAL Page 326 as uln II I FUN lC il\( . State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report during calendar year 2012. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Proc Program of Cases Claims Claims Claims 1:12: Claims Code Description Reviewed Reviewed Reviewed Failed Failed Failed H2015 5 228 18,228 217 17,384 95 2% 0058 H2017 P5y?h?s??ial 5 866 176,215 377 47 523 37 8% Rehabilitation a Grand Total 10 1,094 144,443 544 64,907 49.7% Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker 5 Therapist 28 Nurse 3 Peer Specialist 1 Rehab Coordinator 2 2 Rehabilitation 3 Total Staff Reviewed 49 CONFIDENTIAL Page 327 A r??N A A ?5 a? State of New Mexico II I I Human Services Department PUBLIC Behavioral Health Provider AUditS cucur Final Report lT/Billing Systems Audit System Overview The Anasazi system is used by all of the Rio Grande Network, and while each installation is administered by the individual agency, the differences are really super?cial, such as: The way menus are customized to be displayed per the user roles, 0 How user roles are de?ned, 0 The customization and scheduling of reports and 0 When certain system enhancements are implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Each provider generally deploys the updates to development installations to test and verify the updates before they are deployed into production. The software is installed on the Valencia Microsoft Window Network and is primarily accessed through the Citrix system, which allows all administrative and clinical staff to access the system from any computer. Anasazi would not allow any provider to disclose any training or systems documentation to our auditors, claiming it was preprietary. Bill Processing On a simple level, after services are provided to the client, the clinician updates the ?le with notes and the time and date of encounter. The Anasazi software processes this information and calculates the number of units that the service should be billed for, and what code should be assigned to the service, using the service provided and start and stop times of the service. The service is processed by the Anasazi system and transformed into an 837 billing format, which is uploaded to Optum health through the Optum Netwerkes system. IT Contacts CONFIDENTIAL Page 328 A State of New Mexico Human Services Department [rum lc Behavioral Health Audits Final Report 0 Application Controls - System There are two systems that Valencia users access: the Microso? Windows Network and the Anasazi System. The Anasazi system is accessible both through the Windows network and through any computer that is connected to the internet. For that reason, PCG will only discuss Anasazi access in this report; the Windows network users are held in audit documentation collected by PCG for any required future reference. Administration and Segregation of Duties Agency Administrator Role: Can add users and con?gure data sheets for health plans and services. Administrative Group: Can con?gure data sheets for health plans and services. - Billing Administrator Role: Can convert clinical information into billing information Staff Supervisor Role: Can see clinical records of clients served by clinical subordinates. - Service Provider Role: All clinicians who bill and are on the payroll have the Service Provider Role. Auditor Role: No staff at Valencia Counseling Services currently have the Auditor Role. 0 CONFIDENTIAL Page 329 egg II II I CONSULI INK. State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report IT and Weaknesses Valencia?s billing applications are available from any computer connected to the intemet via Citrix, which make for ease of use from any computer and maintains a uniformly enforced security policy. - Valencia uses Intrusion Prevention Services UPS) which are provided by the NSA 2400 firewall that separates the Anasazi Subnet from the resLo?the LAN and lntemet. These database signatures are dynamically updated on a daily basis to ensure industry standard currency is obtained. 0 Users do not share login accounts. 0 The Anasazi software offers sequestration of clinical information so that users? roles determine the kind of information each user may have access to on a per client basis. For example, a front office clerk may have access to certain demographic information, but 0 Each clinician enters his own billing information. - Each clinician does not know what codes are used for billing the service provided. -. - Anasazi software calculates units billed based on start and end times recorded by the clinician. Anasazi software allows for members of a group therapy session to arrive and leave at different times, allowing for more accurate tracking group services, and therefore billing. Weaknesses: 0 System super user creates the password for everyone but passwords never expire. 0 Disaster Recovery Valencia presented no disaster recovery plans for the application hosting server and electronic records. 0 Currently Valencia IT staff have no knowledge of the application transaction and database transaction logs. The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered. The 837 can be changed when connected to Opturn Networkes. The person uploading the 837 can make any changes to billing with no audit trail. 0 Training is done mostly on an ad hoc basis. Recommendations 0 Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. 0 Develop formalized training system for all users who create charge entry and billing. CONFIDENTIAL Page 330 r-?s A State of New Mexico I I Human Services Department Behavioral Health PTOVider mem- Final Report I Develop Disaster Recovery Plan to manage electronic and paper client records. CONFIDENTIAL Page 331 State of New Mexico Human Services Department rum-K. CONSULHM. Behavioral Health Provider Audits cacur Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Valencia Counseling Services, Inc. (Valencia). PCG began by locating Valencia?s legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on Valencia. PCG located and reviewed Valencia?s audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches on the organization or related individuals. Valencia is a member of the Rio Grande Provider Network and was evaluated simultaneously with Rio Grande Behavioral Health Services and Rio Grande Management. Audit Observations Valencia Counseling Services, Inc. provides counseling services to adults, families, and children having difficulties with their personal lives, relationships with others, alcohol and drug abuse, and social learning problems. Key Staff Sam Vigil Executive Director Joe Castillo President Leo Chavez Treasurer Emestina Morlan Secretary Javier Vera Terri Sturgis Director Carol Long Director Glenna Giles Employee CONFIDENTIAL Page 332 as A A A State of New Mexico ll Human Services Department rum It Behavmral Health auteur Flnal Report Financial Relationships Valencia contracts with Rio Grande Behavioral Health Services, Inc. for the provision of accounting, billing, and human resources. The organization paid $210,000 for these services in 2011'. Rio Grande is a provider sponsored network and each organization?s board members serve as rotating members of the board. While receives fees from its members, it has also distributed various grants back to its members. In addition, Valencia contracts with Rio Grande Management, LLC (RGM), paying $188,000 for management services (2011). These include legal services and the provision of executive management. Providence Service Corporation fully owns RGM. Providence is a large, for-pro?t national corporation providing government sponsored social services directly or indirectly through managed local entities. Providence?s network originated in Arizona and has developed a network of providers serving 70,000 clients in the US and Canada. The Executive Director of this organization is an employee of Providence Service Corporation. In 2012, Sam Vigil, Executive Director, was paid $152,000 from this related organization. In 2012, the organization merged another non-pro?t, La Buena Vida, into the organization and is now operating as a single mental health clinic. Summary of Findings and Recommendations Findings The Executive Director has had an unusual These transactions are unusual for a non- ?nancial arrangement that began in 2002, was pro?t organization and should be evaluated to amended in 2009, and converted existing determine if excess bene?t was provided to ?mding to a single premium immediate this individual. The executive director should annuity plan. $244,000 was added to the plan be evaluated to determine if he is a and brought the organization's investment in disquali?ed person. the plan to $605,000. The amended plan provides $50,000 in annual payments to the director immediately for 17 years with an additional single payment of $100,000 upon Most recent year for which representative payments for both behavioral health and management services were reported. 0 CONFIDENTIAL Page 333 A l?Ullth COVSLILIIM. moor State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report retirement. Upon his death, his bene?ciary receives the balance less any retirement bene?ts already received. ln disclaimers, Rio Grande/Providence member organizations state that management staff may have other responsibilities to Providence. These arrangements make it unclear if the executives charged by Providence are part or full time for this organization. Moreover, without full disclosure, it is dif?cult to determine if the salaries or fees are reasonable. On the surface, the arrangements and amounts paid appear reasonable, but this weak and abnormal public disclosure and may have the effect of masking excessive compensation or bene?ts. In addition, these arrangements circumvent federal disclosure requirements for charities filing Form 990 and make it difficult for the public to benchmark charitable organizations. Full disclosure of executive effort, compensation and bene?ts should be revealed for this organization and for their services to Providence Service Corporation. List of Key Documentation Reviewed Document/Source Year (if applicable) Audited Financial Statements 2012. 2011. 2010 Form 990 (Nonpro?t ?ling) Third-party contracts Organizational charts Interviews 201 1,20l0, 2009 CONFIDENTIAL Page 334 State of New Mexico Human Services Department Behavioral Health Provider Audits [?Lllil IC Final Report auteur Balance Sheet 2010 2011 2012 Assets Cash cash equivalents 1,707,823.00 1,031,791.00 251,812.00 Investments - certi?cate of deposits 1,1 18,764.00 1,121,472.00 1,122,832.00 Accounts grants receivable, less allowance for doubtful accounts 425,277.00 271,378.00 197,646.00 Due form related party 55,254.00 Other Receivables 2,492.00 4,410.00 2,442.00 Prepaid Expenses 40,443.00 40,971.00 67,610.00 Total current assets 3,294,799.00 2,470,022.00 1,697,596.00 Property and Equipment Land, building, furniture, and equipment 1,899,868.00 1,928,387.00 1,943,155.00 Accumulated depreciaiton (905,026.00) (957,506.00) (1,008,689.00) Total property and equipment 994,842.00 970,881.00 934,466.00 Other Assets Single premium annuity 557,653.00 533,305.00 507,837.00 Due ?'om related party 44,415.00 46,973.00 49,150.00 Deposits - 825.00 825.00 Total other assets 602,068.00 581,103.00 557,812.00 Total Assets 4,891,709.00 4,022,006.00 3,189,874.00 Liabilities Accounts Payable 74,576.00 60,933.00 65,312.00 Accrued expenses 71,810.00 67,091.00 85,198.00 Other current liabilities 963,1 17.00 373,960.00 413,479.00 Notes Payable, current portion 3,864.00 4,093.00 4,216.00 Deferred compensation payable 24,348.00 25,468.00 26,640.00 Deferred revenue 1,400.00 Total Current Liabilities 1,137,715.00 531,545.00 596,245.00 Long Term Liabilities Deferred compensation payable 5 533,305.00 507,837.00 481,197.00 Note payable, long term 10,948.00 17,633.00 13,418.00 Total long-term liabilities 544,253.00 525,470.00 5 494,615.00 Total Liabilities 1,681,968.00 1,057,015.00 1,090,860.00 Net Assets 3,209,741.00 2,964,991.00 2,099,014.00 Total Liabilities and Net Assets 4,891,709.00 4,022,006.00 3,189,874.00 CONFIDENTIAL Page 335 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report IV . GROUP 0 Income Statement Revenue Program Revenue and Fees Interest Other Total Revenues and Support Expenses Program Services Management and General 2010 3,541,926.00 36,271.00 5 204,354.00 5 3,782,551.00 2,617,153.00 1,418,916.00 201 3,282,967.00 43,561.00 224,602.00 5 3,551,130.00 2,742,147.00 1,053,733.00 2012 3,036,704.00 37,204.00 5 184,138.00 5 3,258,046.00 3,506,703.00 617,320.00 Total Expenses 4,036,069.00 3,795,880.00 4,124,023.00 Change in Net Assets 3 (253,5l8.00) (244,750.00) 5 (865,977.00) Net Assets, beginning of year 3,463,259.00 3,209,741.00 2,964,991.00 Net Assets, end of year 5 3,209,741.00 2,964,991.00 2,099,014.00 CONFIDENTIAL Page 336 Youth Development Inc. Ciinical Narrative IT Narrative Enterprise Narrative PUBLFC CONSULTING GROUP A A a a State of New Mexico I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI INC. Final Report YOUTH DEVELOPMENT INC. BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review February 27 - March 5, 2013 Main Point of Contact at Facility Extrapolated Date of Service Overpayments $228,309 Actual Longitudinal Overpayments $68,661 Total Overpayments $296,970 Scorecard results are as follows: Sample Compliance Rate Longitudinal Compliance Rate 82% 3% Youth Development. Inc Provider Seem-std .S'Ignffiram A an- Freeman" This scorecard result translates to the following Risk Tier: 3 Signi?cant ?ndings, including 0 Provide trainings and clinical signi?cant quality of care ?ndings. assistance as needed. - Potentially embed clinical management to improve processes. 0 Potential change in management. CONFIDENTIAL Page 337 2'55 State of New Mexico Human Services Department Behavioral Health Provider Audits llNC'. Final Report Provider Overview Youth Development Inc has six locations in the Albuquerque metropolitan area. Within these locations, Youth Development delivers behavioral health services including tutoring, after- school activities, gang intervention, drop?out prevention, family counseling services, emergency teen shelter, youth sports, internships, scholarships, parenting skills, leadership development, public housing assistance, community corrections, GED studies, early childhood education via Head Start centers, substance abuse and AIDS education and other services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations. Payer 5 Claims Paid FY12 5 Claims Paid Audit Period E31) i 8,822 8,822 CYFD 448,971 1,034,640 Medicaid FFS 42,776 93,681 Medicaid MCO 523,431 l,049,054 NMCD 0 0 Other 17,958 758,308 Grand Total 1,041,959 2,944,506 Audit Team Observations - An entrance conference was held within two hours of the team?s arrival onsite.- was offsite 5? was designated to serve at the team?s point of contact at the site. Also participating in the entrance conference was 0 Case ?les began to arrive within an hour of the conclusion of the entrance conference. The majority of ?les were provided within two business days. A number of ?les were provided later because they had to be retrieved from storage. Two case ?les could not be located. 0 All case ?les and supervision logs were provided in paper format and the FCC audit team manually pulled the necessary documents from the case ?les. Personnel ?les were provided in electronic format. CONFIDENTIAL Page 338 PUBLIC CONSULI INC GROUP State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report 0 Case ?les had a de?ned organizational format that was observed in the majority of case ?les reviewed. 0 staff was prompt in responding to audit team requests for clari?cation or additional information. I Clinical Reviewers noted the following general ?ndings: 0 Comprehensive Clinical Assessments were not always provided to determine/support medical necessity for the billed service or the provided assessments were incomplete of critical information for the date of service under review. Treatment plans were missing, not up to date, and/or not individualized per consumer. Progress Notes/Recipient Documents were missing, incomplete, and insu?icient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and ?fty (ISO) random date of service claims for July I, 2009 through January 2013. Below is a table showing the relevant programs that were included in random audit sample and the resulting ?ndings: a br 5 Value at 5 Value Procedure . . . . . Claims Code Program Description Claims Claims Claims Claims Failed Reviewed Reviewed Failed Failed Diagnostic 9080] Evaluation 4 350 0 0 0.0% 90804 Outpatient?2060 minutes 6 266 0 0 0.0% 90806 Outpatient?4560 minutes 44 2,884 I 60 2.3% 90808 0utpatient?7S-80 minutes 13 972 0 0 0.0% 90846 Family Therapy 4 2.54 0 0 0.0% 90847 Family Therapy 16 Li 98 0 0 0.0% 90853 Group Therapy [6 383 0 0 0.0% H0041 Foster Care(Shelter) l3 6,728 0 0 0.0% H2011 Crisis Intervention SchiCes 7 3 l8 0 0 0.0% CONFIDENTIAL Page 339 A a State of New Mexico II I Human Services Department Behavioral Health Provider Audits IL CONSLII IINC. Final Report (lltOUl' H2015 HO, HN, 27 2,055 26 1,922 96.3% Grand 150 15 408 27 982 18.0" Total A Speci?c Random Sample Review Findings For each program reviewed, PCG identi?ed the level of compliance and any speci?c areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG identi?ed: CONFIDENTIAL Page 340 aa?? ll PUBLIC CONSULTI NC 90806 Pass NA NA Pass Fail Pass NA NA NA 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Practitioner is not on agency roster NMAC 8310.8. H2015 Pass Fail Fail Fail NA Pass NA NA NA Missing Dowmentation treatment plan. Missing Documentation treatment plan. CSW did not dowment assessment of safety [monitoring of at risk situations. NMAC 8315.6. Missing Documentation treatment plan. H2015 . Pass Pass Pass Pass Fail NA NA NA Practitioners quali?cations were not submitted NMAC 8315.6. Agency listed themselves as practitioner H2015 Pass Pass Pass Fail Fail NA NA NA Practitioners quali?cations were not submitted NMAC 8,315.6 Although there was a service note provider is ineligible to provide services. H2015 Pass Pass Fail Fail NA Fail NA NA NA Session occurred at the agency of?ces NMAC 8315.6. Met with member to sign consent paper work did not document if she assessed for safety issues or at risk situations. NMAC 8315.6. Practitioner did not meet quali?cations. H2015 Fail Pass Pass Fail NA Fail NA NA NA Missing documentation assessment. Documentation by the CSW does not indicate that she and the member worked on skill building or accessing services or skills that would help member improve his life at home or at school. Documentation does not support units biled NMAC 8315.6. Missing documentation assessment.- lot quali?ed per staff roster. H201 5 Fail Pass Fail Fail NA Fail NA NA NA Missing documentation assessment. Documentation states that CSW went by members home and no one was there. NMAC 8315.6. Documentation states that CSW went by members home and no one was there. NMAC 8315.6.- ot quali?ed per staff roster. CONFIDENTIAL Page 34} Pi? PUBLIC H2015 l'l2015 H2015 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Pass Fall Fail Pass NA Fall NA NA NA No estimated I tor discharge plan noted in crisis treatment plan. ot quali?ed per staff roster. No speci?c community support services noted in crisis plan. Pass Pass Fail Fail NA Fail NA NA NA Documentation does not state why mom wanted this meeting with JPO and CSW. NMAC 8315.6. Documentation does not state why mom wanted this meeting with JPO and CSW. NMAC 8315.6. Documentation does not support units billed NMAC 8.3.15.6. Practitioners quali?cations were not submitted NMAC Fail Recipient Pass H2015 Assessment DOS Screening Pass Treatment Plan Pass Fail Service Delivery Pass Fail i Progress Notes Fail NA NA Billing Fail Staffing Fail NA Consent Forms NA NA Pharma NA NA Other NA Missing Documentation assessment. CSW did not meet with the member. Transcript was picked up by CSW at his school. This should have been a parent duty. NMAC 8315.6. CSW did not document assessment of safety [monitoring of at risk situations. NMAC 8.315.6.?not quali?ed per not quali?ed per staff roster. Comments CSW did not document assessment of safety [monitoring of at risk situations. NMAC 8,315.8. Practitioners qualifications were not submitted NMAC 8.3156. Practitioners quali?cations were not submitted NMAC 8.3156. Pass I'l2015 Fail Fail Fail NA Fail NA NA NA Missing Documentation NMAC 8.3156. quali?ed per staff roster staff roster quai Fail H2015 Pass Pass Pass NA Fail NA NA Missin documentation assessment NMAC 8,315.6. ?nal quali?ed per roster. Pass Fail Pass Fail NA Fail NA NA CSW did not document assessment of safety [monitoring of at risk situations. NMAC 8315.6. Documentation does not support units billed NMAC 8.3158. Practitioner doesn?t meet standard ?iMAc 5.3155. No support service needs documented on safety/crisis plan dated 10-6-11. CONFIDENTIAL Page 342 A gag? ll PU CONSULTING GROUP 0 State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report H2015 Pass Pass Fail Fail Fail NA NA NA Documentation did not state what was done at the home visit. visited with member nmac 8315.6. did not state what she worked on with the client nmac 8,315.6. did not document assessment of safety [monitoring of at risk situations. Nmac 8315.6. Practitioners quali?cations were not submitted H2015 Fail Fail Pass Fail NA Fail NA NA NA Missing documentation NMAC 8.3156. Service Plan for CCSS was not submitted, only service plan for Amistad Crisis Shelter NMAC 8.3156. CSW did not document assessment of safety [monitoring of at risk situations. NMAC 8315.6. Missing documentation NMAC 8.315.6._ot quali?ed per staff roster. 0638 service plan NMAC 8.3156. H2015 Pass NA Pass Fail NA Fail NA NA NA CSW did not document assessment of safety [monitoring of at ris s? AC 8315.6: Missing documentation: education forWMissing document: -not on staff roster, tile not complete. Listed facihty as the practitioner. NMAC 8.3156; LOC 8.315.69: Service De?nition. H2015 Pass Pass Pass Fail NA Fail NA NA NA Documentation does not support units billed NMAC 8315.6. Practitioner is on the company roster but did not have appropriate quali?cations. NMAC 8315.8; LOC 8.315.69. H2015 Fall Fail Fail Fail Fail NA NA NA Assessment was dated 315108 service date for member is 10/1610?! assessment is out dated NMAC 8315.6. Plan or revision done by service date 10/1 BIOS CSW did not document progress or lack of progress toward treatment goalslobjectives NMAC 8315.6. Last treatment plan update was 7I1I09 no new tx plan or ision done by service date NMAC 8315.6. CSW d' not document assessment of safety [monitoring of at risk situations. NMAC 8.3156. CSW did the intervention at school. tlnable to read documentation clearly. Treament plan had not been updated. NMAC 8315.6. 02: Diagnositic Impressions dated diagnostic review had not been completed since 2/15108 NMAC 8,315.6. Agency was used as the rendering the service CONFIDENTIAL Page 343 State of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC Final Report LROU in?ll instead 01 csw. NMAC 8.315.6. Agency was used as the rendering the service instead of csw. NMAC 8.3156. Old diagnosis 305.20 and 305.00 no new assessment submitted. NMAC 8315.6. Assessment need to be updated not valid NMAC 8.3156. .. . Consent Progress Billing Pharma Other Comments Notes Forms Recipient Assessment Treatment Service DOS 1? Screening Plan Delivery Missing documentation NMAC 8315.6. Two separate contact telephone notes. One was to the member?s sister and the other was to?at DHNM regarding H2015 Fail Pass Fail Fail NA Fail NA NA NA discharge meeting total phone time 1.5 or 6 units NMAC 8.3156. 60% of CCSS must be invivo. The documentation that was submitted all interventions were done via telephone. Practitioners quali?cations were not submitted NMAC 8315.6. 1 CSW did not document assessment of safety [monitoring of at . . I risk situations. NMAC 8315.6. Documentation does not support ?ms 1 Pass Pass Pass Fa" NA Fa" NA NA NA units billed NMAC 3.315s. Practitioners quali?cations were not submitted NMAC 8315.6. H2015 Fail FaMissing Documentation NMAC 8.3156. Provider is not on the agency roster NMAC 8.3156. CSW did not document assessment of safety [monitoring of at H2015 Pass Pass Pass Fail NA Fail NA NA NA risk situations. NMAC 8315.6. Practitioners did not meet quali?cations NMAC 8.3156. Missing document: progress note for billed service. Progress H2015 . Pass Pass Fail Fail NA Fail NA NA NA note documents individual -lid not 1 meet qualifications for a CSW. Missing Documentation iriress note for date of service 12/7109. . . . NMAC 8 315.6. not ?sted as a CSW to do CCSS. H201 5 Pass Pa SS Fa" Fad NA Fall NA NA NA Practitioners quali?cations are unknown if they meet standards for CSW. NMAC 8.3156. CONFIDENTIAL Page 344 CONSULI INC H2015 W5 WT State of New Mexico Human Services Department Behavioral Health Provider Audits Final Report Fail NA Missing documentation NMAC 8315.6. Practitioner?s name is not on agency roster NMAC 8315.5. Fail NA Missing Dowmentation assessment. No in or out time on progress note. Missing documentation not on staff roster or staff fotder. No specific community support needs noted on treatment plan. CONFIDENTIAL Page 345 A State of New Mexico I Human Services Department i Behavioral Health Provider Audits I?LllilJL Final Report Sampling De?nition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary in order to produce a valid sample. In a random sample, claims are selected from a population in such a way that the sample is unbiased and closely re?ects the characteristics of the population. Sampling Frame Size: Total number of claims from universe of claims from which the sample was selected. Sampling Unit: The entire claim amount. Time Period: 7/ l/2009 l/20l3 Sample Size: Sample size is ISO claims. Extrapolation: The overpayment was identi?ed using the lower bound of the 90% con?dence interval. Youth Development Sample Size 150 Total Paid for Sample $15,048 Sampling Frame Size 26,343 Number of Sample Claims with Overpayments 27 Tentative Overpayment Using Lower Bound of the 90% Con?dence Interval $938,309 Longitudinal File Review PCG selected between one and ?ve of high risk procedure codes at each reviewed provider and then selected the ?ve recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of mo percent of the claims associated with each selected procedure code and recipient which were paid 0 CONFIDENTIAL Page 346 A State of New Mexico Human Services Department I Behavioral Health Provider Audits ING Final Report during calendar year 20l2. Below is a table showing the relevant programs that were included in longitudinal ?le review and the resulting ?ndings: Free Program Cases Claims 5 Claims fit-Claims 2:11]? Claims Code Description Reviewed Reviewed Reviewed Failed Fail?: Failed H0041 Fm39/ Care(Shelter) HO, HN, 0 H2015 CCSS 5 253 29,695 25! 29,403 99.2 xi: Grand Total 10 306 74,051 297 68,661 97.1 Provider Credential Review For all random date of service claims and longitudinal ?les reviewed, PCG requested provider credential information for each of the clinicians or other staff that had rendered the service. The table below shows the number of staff reviewed by provider type: Provider Type Reviewed Community Support Worker '7 Therapist 13 Residential Worker 14 Intervention Specialist 1 Unknown/Other 16 Total Staff Reviewed 51 CONFIDENTIAL Page 347 as A r-a 4,74% State of New Mexico I Human Services Department 0 Behavioral Health Provider Audits CONSUHING Final Report moor Billing Systems Audit System Overview For most of its billing, YDI uses El Perico, a clinical and billing system that integrates intake, clinical notes and billing. While YDI does have a Microsoft network?system, it-is used only as ?le server and does not contain any billing or clinical information. All billing is performed on three separate systems that process information in the cloud: 0 El Perico, their main billing system. All billing that is billed hourly or for the service is billed through Perico. - Optum Netwerkes, on-Iine EDI clearinghouse. El Perico creates the 837 and it is uploaded through Optum Netwerkes. I Optum Provider Portal on-line portal is used to bill services that are billed at day rates - shelters, etc. 0 _reports that Optum Health recommended El Perico to YDI. She cannot recall which staff member(s) made the recommendation. 0 IT Contacts: 0 Application Controls - System Administration and Segregation of Duties User Roles Agencv Administrator Role: Can create new users and set up new payers/insurance plans. 0 CONFIDENTIAL Page 348 A A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULI le. GROUP - Billing Administrator Role: Can create new services and generate billing. - Staff Supervisor Role: Can access clinical records of staff that is supervised by each supervisor. Final Report Community Support Workers (CS W) Service Provider Role: All clinicians who bill and are on the payroll have the Service Provider Role, which can add clinical services to clients assigned to them. Auditor Role: No staff at YDI currently have the Auditor Role. IT and Weaknesses YDl?s billing applications are in the cloud, which make for ease of use from any computer and uniformly enforced security policy. 0 Users do not share login accounts; new passwords are required every 90 days. - Each clinician enters her own charges. Weaknesses: Application controls may be compromised by the following application risks. 0 The point of entry to the claims payment system provides the ability to change any billing from what the clinician entered: In El Perico, the 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 can make any changes to billing with no audit trail. 0 ln Optum Portal, the clinicians can repot a certain number of days, but both the source documents and what is entered in the portal can be changed by staff entering the information. 0 Training done mostly on an ad hoc basis. Without a formal training and tracking system, uniform direction as to the use of the system cannot be guaranteed or tracked. - Disaster Recovery El Perico demonstrated adequate disaster recovery plans through its application hosting service arrangement, but YDI presented no disaster recovery plans for all of the paper client records in its possession. CONFIDENTIAL Page 349 as A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC ONSUI IINL Final Report Recommendations 0 When and if ?nancially feasible, migrate to Electronic Health Records to integrate the health record with the billing system, to have tight controls between clinical and billing processes. 0 Create audit trail for any changes made to 837 ?les when they are uploaded to the clearinghouse. 0 Develop appropriate accounting controls for charge entry/billing in Optum Portal. 0 Develop Disaster Recovery Plan to manage paper client records. 0 Develop formalized training system for all users who create charge entry and billing. CONFIDENTIAL Page 350 as A State of New Mexico I I Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report Enterprise Audit Provider Speci?c Methodology PCG utilized a consistent, systematic approach to conducting the enterprise audit of Youth Development, Inc. PCG began by locating YDl's legal entity, its of?cers, and organizers. PCG also reviewed initial founding and leadership information on YDI. PCG located and reviewed YDl?s audited ?nancial statements and tax data. PCG recorded and reviewed recent of?cers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential con?icts of interest. PCG assembled the ?nancial data and analyzed it, looking at key ratios, trends, and tracking variances. PCG tracked the organization?s addresses and reviewed ownership of property online or through the county assessor?s of?ce. Finally, PCG performed media and court record searches 0 on the organization or related individuals. Youth Development lnc. is a member of Partners in Wellness which was reviewed simultaneously. Youth DeveIOpment Inc. has a related organization, Foundation, lnc. that exists to collect, manage, and distribute funds and properties for the bene?t of the organization. The ?nancial interests of both organizations are pooled in consolidated ?nancial statements. Audit Observations Youth Development Inc. provides services to youth of New Mexico including residential care, youth employment and education, counseling, outreach, substance abuse prevention, gang prevention and community corrections programs. Key Staff First Name Last Name Position Robert Avila Chair Joe Bowdich Vice Chair Priscilla Gonzales Secretary Andres Trujillo Member CONFIDENTIAL Page 35l a A State of New Mexico I Pluman Services Department 0 ehavtoral Health Prowder Audits PUBLIC llNC. Final Report Debra Singletary Member Grace Chavez Member Judge Diane Dal Santo Member Ramona Sanchez Member Judge Violet Otero Member Michael Padilla Member Patrick A Baldonado Treasurer Johnise Monae Pena Member Conrad Candelaria Member Mary Rose Holtry Member Augustine Baca CEO John Melendez CFO Stephen Fortress COO Debra Baca VP/Headstart Ryan Patrick Griego Member Ramona Padilla Member Financial Relationships The president of is also the President and CEO of YES Housing. leases of?ce space to YES and leases commercial of?ce space from YES. Summary of Findings and Recommendations Findings Recon]mcmlations None List of Key Documentation Reviewed Document/Source Year (if applicable) 201L2010. 2009 2011,20l0,2009 Audited Financial Statements Form 990 (Nonpro?t ?ling) Contracts Org Charts CONFIDENTIAL Page 352 Aer?s 4% A State ofNew Mexico Human Services Department Behovroral Health Prowder Audits PUBLIC INC Final Report LRDLIP . Balance Sheet 2009 2010 201 I 2012 Asset: Cash cash equivalents 62346 54.828 21.940 147.121 Grants receivable 2.331.392 2.800.782 2.462.300 2.137.768 Other receivables 157.973 208.456 196.67] 32.977 Other current assets 6.745 7.335 7.337 21.103 Land 786,440 786.440 5 786.440 786.440 Buildings 6.063.382 6.137.548 6.137.548 6.137.546 Equipment 2,515,559 2,600,402 2.548.404 2.543.620 Vehicles 5 1.450.728 1.680.562 1.846.190 1,825,289 Fumiture ?xtures 480,978 483.362 483,363 483,363 Accumulated depreciation (5.312.771) (5.830.558) (6.346.296) (6.716.902) Other Iong-tcmt assets 152.810 Total Assets 8 8.542.772 8.929.157 8.143.897 7.551.135 Liabilities Cash overdra? 82.271 94.617 165.758 201.344 Accounts Payable 570.849 665.809 1.000.957 374.629 Accrued liabilities compensated absences 677.733 868,425 1.182.304 1.127.451 Deposits held for others 220,259 201.099 8.795 - Line-of-eredit 661.132 1,363,096 237.382 266.344 Current portion of long-term debt 76,700 76,700 164.200 725,968 Deferred revenue 255.603 153,560 1.026.880 1.614.810 Long-term debL net ofcum-nt portion 799,371 722.675 558,270 - Total Liabilities 3.343.918 4.145.981 4.344.546 4.310.546 CONFIDENTIAL Page 3 3 A A 7 State of New Mexico I Human Services Department Behavioral Health Provider Audits CONSULI Final Report GROUP Net Assets 5.198.854 4.783.176 3.799.351 3.240.589 Total Liabilities and Net Assets 5 8.542.772 8.929.157 8.143.097 7.551.135 Income Statement 2009 2010 201i 20I2 Revenue Grant income 22,949.820 24.145.624 25.055.423 25.712.622 Contributions 5 402.953 5 561.591 5 I25.725 5 249.637 ln-kind donations 781.462 769.667 5 830.326 5 607.371 Other income 462.038 5 218.261 481.616 I4I.819 Net assets released from restrictions 5 - - - Total Revenues and Support 24.596.273 25.695.143 26.493.090 5 26.71 L449 Expenses Residential care 5 625.175 5 596.996 5 543.925 535.641 Youth cmplo; ment cducat ion 5 16,307,340 5 I 7.804.029 17.961738 17,297,534 Counseling communit} outreach 3.103.664 3.036.805 5 4.1611 17 4.969.133 Substance abuse prevention 5 170.527 84,080 5 83.500 83.500 Community correction gang intervention 1.447.902 1.282.187 l.l53.7l4 ?23.056 Health issues 5 441.845 5 229.081 5 206.1 13 l22.906 Management general 5 3.084.769 3.077.643 2.748.291 2.710.505 Total Expenses 25.181.222 26.! l0.82 26.865398 26.842.275 Change in Net Assets 5 (584.949) 5 (415.678) 5 (372.308) "30.8261 Depreciation Expense (61l.511) 5 (427.936) Change in Net Assets depreciation expense) 5 (983.825) 5 (558.762) CONFIDENTIAL Page 354 Ag A Stale of New Mexico Human Services Department Behavioral Health Provider Audits PUBLIC CONSULTING Final Report GROUP Nel Assets. beginning of year 5 5,783,803 4.183.l76 3.799.351 Net Assets. end of year 5 5.98.854 4.783.176 5 1799.35] 5 3.240.589 CONFIDENTIAL Page 355