By Steve Hansen
QCS managing editor
Teambuilders Counseling Services, Inc., which provides counseling and other services in Clovis, Portales and Tucumcari is among 15 behavioral health providers facing a criminal investigation after a statewide audit found rampant overbilling and potential fraud at these providers’ facilities.
New Mexico’s Health and Human Services Department ordered the audit after OptumHealth, the company that provides billing services for HSD’s behavioral health providers, flagged irregularities in billing practices last November.
An immediate consequence of the audit findings is that payments to Teambuilders from HSD for Medicaid services have been cut off.
As of Thursday, HSD had not acted on Teambuilders’ request for a “good cause exception,” which would allow payment for services while investigations continue, said Matt Kennicott, HSD spokesman.
HSD has awarded such exceptions to the Counseling Center in Alamogordo and the Service Organization for Youth in Raton, and Easter Seals el Mirador in Santa Fe, which were also faulted in the audit, Kennicott said.
Teambuilders is continuing to operate programs and services for its clients statewide “as we always have,” Shannon Freedle, Teambuilders’ Chief Executive Officer, said, and has reserves on hand to keep operating for “a couple months.”
Freedle said he hopes HSD will resume payment by then, but did not comment on what would happen if payment continues to be withheld.
In fiscal year 2013, Teambuilders served 849 individuals (children and adults) from Curry County, 253 from Roosevelt County and 147 people from Quay County, Freedle said.
The attorney general’s office expects that its preliminary evaluations of audit data and its own data-collection efforts are likely to take months, said Phil Sisneros, director of communications.
“This investigation will be huge,” he said. “Our resources are severely strained, and we may have to seek out alternative resources.”
Sisneros said the probe may require additional attorneys and investigators to be hired temporarily, and the attorney general’s office may have to seek additional funding from legislative sources to conduct this investigation.
HSD has made a preliminary arrangement with five Arizona-based behavioral health providers to take over services for HSD programs in New Mexico, Kennicott said.
Freedle said the audit results took him by surprise. He said HSD has never questioned Teambuilders on their practices or billing before.
In addition, he said, Teambuilders has received exemplary status from the Children, Youth and Families Department for compliance with regulations on billing.
Freedle also expressed frustration at being unable to examine the auditors’ detailed data to find out how they collected and analyzed data, or to determine the standard the auditors used to draw their conclusions about Teambuilders and other providers.
HSD’s Kennicott said that federal law prohibits the release of a audit findings or methodologies when allegations of fraud are turned over to the Attorney General’s office.
“These are all part of an ongoing law enforcement investigation,” he said, “and releasing this information could potentially jeopardize the investigation.”
On Wednesday, several New Mexico lawmakers said the state’s largest behavioral health providers have been smeared by the suspension of funding and the secrecy surrounding alleged wrongdoing, according to Albuquerque Journal reports cited by the Associated Press.
Senate President Pro Tem Mary Kay Papen said the HSD audit was an attempt to divert attention from its own mismanagement problems, the report stated.
In its summary of audit findings, HSD said “each of the 15 providers audited failed to meet minimal compliance standards, with error rates far exceeding national documented averages, and $36 million in definitive overpayments have been identified.”
The $36 million represents 14 percent of payments made to the agencies, the report said.
The 14 percent rate of overpayment exceeds the federal General Accounting Office’s standard of 3 to 9 percent of all payments that are found to be fraudulent, the summary stated.
“Even after removing the claims submitted with human documentation errors, the audit found that more than 25 percent of the audited claims should not have been billed,” the summary stated. “When HSD examined the case files which impact health and safety of individual consumers, a more than 57-percent error rate was discovered.”
Further, the report said without listing names, “the audit results point to potential fraudulent activity by certain behavioral health executives.”
HSD officials have discussed the audit findings with U.S. Attorney’s Office, the New Mexico Attorney General’s Office and other law enforcement agencies, the summary report says.
The auditors, Public Consulting Group of Boston, Mass., conducted three kinds of audits, a statement said. They include:
1) Clinical case file audit — a review of case file documentation, including staffing qualifications 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.”
The HSD audit followed OptumHealth’s reporting of irregularities in the behavioral health system as a whole last November.
Issues that OptumHealth found among the 15 providers that were audited include:
• Practitioners billing long hours, providers billing long days for consumers.
• Providers improperly unbundling services that were supposed to be bundled.
• Providers using excessive billing of specific codes, or billing for two services but only providing one.
• Overuse of codes.
• Billing for one consumer at two providers with a business relationship on the same date of service.
• Cross-billing for mutually exclusive codes on the same day at the same provider or at different providers for the same consumer.
• Linking of one provider’s electronic medical records system to a separate provider’s electronic medical records system when the two providers did not have a disclosed business relationship.
The Public Consulting Group made the following recommendations to HSD to avoid future overbilling and potential fraud, based on the consulting firm’s findings:
• Adopting standardized documentation and forms to assure that consumer information is gathered an properly documented.
• Supplementing current billing practices with pre-payment measures and more provider education, oversight and monitoring efforts to prevent errors from occurring prior to payment.
• Technical assistance to providers in the areas of clinical best practices and billing processes and procedures.
• Reviewing and revamping New Mexico’s behavioral health provider billing rules and regulations, using best practices that the consultant recommends.
• Making best use of the editing capabilities of claims processing systems to prevent overpayments.