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Legislators question health care audit

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Providers hurt by secrecy, funding loss, lawmakers say

SANTA FE – The Human Services Department is getting pushback from some lawmakers who say the state’s biggest behavioral health providers are being smeared by the suspension of their funding and secrecy surrounding their alleged wrongdoings.

Senate President Pro Tem Mary Kay Papen, D-Las Cruces, a longtime advocate for the mentally ill, said HSD is trying “to divert attention from its own and OptumHealth’s mismanagement of behavioral health services and expenditures.”

Human Services Secretary Sidonie Squier last week halted Medicaid and other funding to 15 providers, saying an in-depth audit by a Boston firm showed $36 million in overpayments over three years, widespread mismanagement and possible fraud.

The audit results were turned over to the attorney general and, except for a summary from the department, have not been released to the providers or the public.

Providers can apply for exceptions to the payment freeze.

The Human Services Department said Tuesday that behavioral health funding has been resumed to Service Organization for Youth, in Raton, and The Counseling Center in Alamogordo, on the condition they get intensive retraining and monitoring.

The department has lined up five Arizona contractors to provide training and oversight of the nonprofits at a potential cost of $17.8 million.

Papen, in a written statement, said the state’s Behavioral Health Collaborative and its contractor, OptumHealth, are supposed to oversee the providers.

“Instead of bringing in more managers, we should require the ones we already have to do a better job,” Papen said.

The lawmaker complained the providers haven’t been given an opportunity to explain or defend themselves, or come into compliance, and that HSD’s handling of the audit results “has been without regard for the professional reputations” of the providers.

HSD spokesman Matt Kennicott said federal regulations require that specific audit information not be released, “as doing so would negatively affect the attorney general’s investigation.”

Sen. Gerald Ortiz y Pino, D-Albuquerque, co-chairman of the Legislature’s interim Health and Human Services Committee, said it “just does not sound right” that all of a sudden there’s a fraud problem involving providers who have served the state for decades.

“I don’t believe you should be able to spend $17 million of taxpayers’ money rectifying problems you’re not willing to specify,” the lawmaker said.

“I want information. … If there were mistakes made, tell us what they are,” said Sen. Gay Kernan, R-Hobbs, an interim committee member who worried about the impact of the funding cutoff on services to substance abusers and the mentally ill.

HSD’s Kennicott said the agency has “extensive plans in place” in the event of service disruptions, but that providers have “a contractual and ethical obligation” not to close their doors.

Roque Garcia, CEO of Southwest Counseling Center in Las Cruces, notified his staff on Tuesday that he deposited personal funds into the nonprofit’s account to keep it afloat through July 13.

“SWCC has been in Las Cruces for 50 years, and now we all stand accused of fraud without the ability to clear our names. … All our past audits have been good to excellent,” he said in an email to staff.

A May 2011 letter from OptumHealth gave SWCC scores of 92 percent and 98 percent for reviews of the facility site and treatment records.

Scores of 85 percent are considered passing.

Another big provider among the 15, TeamBuilders Counseling Services, got scores in the spring of 2012 of 100 percent and 97.8 percent for the same reviews.

Elizabeth Martin, CEO of OptumHealth New Mexico, said the firm has “referred potential cases of fraud, waste or abuse to the state, in accordance with state guidelines,” since it began work in 2009.

Optum said it reviews all claims each month to identify billing irregularities and other suspicious activity; findings can trigger further billing audits, as can tips to a waste, fraud and abuse tip line.

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