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AHLA's Speaking of Health Law
Exploring the Rise of Medicaid Payment Suspensions Targeting Behavioral Health Providers
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Medicaid payment suspensions are one of the most powerful tools the government has in the health care enforcement space, and the current administration has taken a robust approach to their use. Sarah Hall, Partner, Epstein Becker & Green PC, speaks with Clifford Barnes, Managing Partner, Clifford E. Barnes Esq. & Associates LLC, and Tom Barnard, Shareholder, Baker Donelson Bearman Caldwell & Berkowitz PC, about the rise of Medicaid payment suspensions targeting behavioral health providers in Washington, DC. They discuss the mechanics of a Medicaid payment suspension, the specific trends they have recently seen regarding DC Medicaid, and what Medicaid providers can do to prevent suspension.
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SPEAKER_03All right. Thank you for tuning in, everyone. My name is Sarah Hall. I'm a partner with Epstein Becker and Green in Washington, D.C., and I'll be your host today of a really exciting podcast that we have for you. I'm joined by Clifford Barnes and Tom Barnard, who will introduce themselves in just a moment. But I'll just go ahead and give an overview of our topic for today. So today we're going to talk about Medicaid payment suspensions, which are administrative remedies, but without a doubt, one of the most powerful tools the government has in the healthcare enforcement space. As a case study today, we will focus on the rise of Medicaid payment suspensions targeting behavioral health providers in Washington, D.C. And we know that many AHLA members are very concerned with criminal enforcement by various U.S. attorneys' offices around the country, as well as the corresponding Medicaid fraud control units or mufuku's that often occur concurrently with these payment suspensions. The topic is especially timely and significant given that the Trump administration has made cracking down on healthcare fraud with an increasing emphasis on Medicaid fraud, a key domestic policy initiative. So again, I'm your host, Sarah Hall. I'm a partner with Epstein Becker and Green, Washington, D.C. I'm a former federal criminal health care fraud prosecutor with the Department of Justice. And at Epstein Becker and Green, I defend individuals and companies in civil and criminal healthcare fraud enforcement. And let me turn it over to my colleague Cliff Barnes to introduce himself.
SPEAKER_00Good afternoon. My name is Cliff Barnes, and my practice is a regulatory practice, mergers, acquisitions, and regulatory work. I have worked a great deal in the behavioral health and fraud space, particularly in DC. Thank you.
SPEAKER_03All right, great. And last but not least, my colleague Tom Barnard. Tom, will you introduce yourself to our listeners?
SPEAKER_02Yeah, thank you. Thank you, Sarah and Cliff. It's my pleasure to be here. My name is Tom Barnard. I'm a shareholder at Baker Donaldson, where I also practice in government enforcement of civil and criminal matters, primarily in the healthcare industries. I was a former assistant U.S. attorney in the District of Maryland for a while. And, you know, I definitely work with Sarah and others in these kind of issues regularly. And I enjoy um enjoy being part of the AHLA programs. So thank you, Sarah.
SPEAKER_03All right, great. Well, we're gonna have a really interesting conversation today. Um, so I'm just gonna set the table very briefly by talking um about Medicare suspensions, because as we all know, all of us who practice in the healthcare space, we know that Medicare is the sort of the big player in the funding of healthcare in the United States, with Medicaid sort of uh coming in a distant second. But in the in the context of what we're talking about today, the suspension, a payment suspension, where the Medicare or Medicaid comes in and suspends payments to providers. Um, you know, traditionally in the Medicare space, um, you know, we've seen over the you know decades of experience that we have collected here today, amongst myself, Cliff, and Tom, that Medicare payment suspensions have been fairly rarely used. And that's due to a variety of factors. It's a very drastic measure, it's a drastic remedy because the HHS has traditionally and CMS has traditionally been very concerned that stopping payment to Medicare providers will mean that patients will not get the services that they need. Um, and so we haven't seen a lot of those historically. Um, now just to note that very recently um CMS took pretty dramatic action in coordination with Vice President Vance's anti-fraud task force, and that included the suspension of payments to approximately 800 hospices and home health agencies suspected of fraud in Los Angeles, California. Um but by contrast, where CMS or HHS, the feds may or can suspend Medicare payments to providers upon receiving a credible allegation of fraud, which is the legal standard we'll be focusing on today, the state Medicaid agencies are generally required by federal regulations that govern their operations to go ahead and suspend Medicaid payments to a provider when a credible allegation of fraud is identified. And so it's a different regulatory framework. It's a it's a it's a can versus shall. And then, you know, in addition to the regulations which require those state Medicaid agencies to suspend payments upon this credible allegation of fraud, which Cliff was going to get into in a minute, um, state Medicaid agencies these days, in the political climate we're living in now, may be more apt to issue those suspensions given the Fed's current intense interest on Medicaid, also the current uh decertifications of several Mufukus, New York and Hawaii, at the time of this recording in mid-July, and the overall heightened federal focus on Medicaid fraud. So we may see more and more of these Medicaid suspensions as we will get into the podcast. So let me start with Cliff. Cliff, you and I have done a lot of these cases together over the years that we've worked together. And um, let's walk through for our listeners the mechanics, the sort of the um the basic mechanics of a Medicaid payment suspension. So as I mentioned in the lead-in under the Medicaid regs, a state Medicaid agency is required to impose a payment suspension if there's a credible, quote unquote, credible allegation of fraud. That's the terminology from the regulations. Cliff, what is a credible allegation of fraud? What does that mean?
SPEAKER_00Yeah, no, good question, Sarah. And I think your point about the regulations with respect to Medicaid that requires uh a suspension when there is quote unquote a credible allegation of fraud. And what is a credible allegation of fraud? It is an allegation that has an indicia of credibility. Uh, and it's got to be based on investigations and activities of the state which are judiciously uh employed. Uh and so what that means as a practical matter is that anyone who is subject to a suspension would need to show that the particular provider uh that there is insufficient evidence of fraud. Uh and uh when you think about an an indicia of reliability, uh what is that? It it sounds very small, that's for sure. Uh, but fundamentally, uh what a defendant would need to do, what a provider would need to do is to show that there is insufficient evidence of fraud or that there is some kind of uh arbitrary and capricious uh employment of investigatory um uh uh uh discretion. Uh and so uh let's step back in terms of the mechanism. Uh and and this is employed even before there is a complete investigation. This is before there is a determination of fraud, and many times it is before any notice to the individual provider. So at any given day, in any given moment, a provider could receive a letter that says their payments will be suspended, and that day the payments are suspended. And so the individual provider then has to figure it out in real time with no money coming in, uh what does this mean for them and their operation?
SPEAKER_03Right. And so, you know, as you mentioned, um in the, you know, Tom and I come from the DOJ world where there are lengthy investigations, whether they're civil, whether they're criminal, the government builds its case. And by the time you get either an indictment or a complaint under the False Claims Act, um, or a CID under the False Claims Act, there's there's a fairly developed body of evidence that's being brought to bear against the provider. But as you're referring to, Cliff, in this context, these investigations are at a very uh sort of preliminary stage. Is that is that accurate to say?
SPEAKER_00Yes, uh very preliminary. And indeed, these allegations could merely be based on a hotline complaint. It could be based on a preliminary data analysis from data mining. Uh in other words, there is no requirement that there be a finding of fraud. There is just facts that tend to show that it may be fraud. Uh and so it switches the presumption in effect so that the individual provider then really has to show that there is no fraud. Uh and that that's the bottom line.
SPEAKER_02Sarah, because you know what I think is kind of interesting about that, as I hear you talking about it, Cliff, is just a couple of contrasts, is you think why they want to prevent it from going out, but if they had to seize it, we know they'd need probable cause to seize it. So the standard is a lot less than probable cause because it's gonna the money's never leaving the government's hand. That's really why you'd want to suspend rather than try to get it back later, and why we know it's a probably a much lower standard. Then two. What I find crazy about this in some ways is the money that's being denied being payment is for services actually rendered. And there's no requirement to show that the money that's pending that you're stopping is earned by fraud. It could relate to fraud unrelated to that money. So when you think about it in in parallel to things like forfeiture analysis or other type seizures, there's no there's no requirement to show that the money that's being withheld in question, even though possibly lawfully earned, is being kept as proceeds of fraud. It it could be totally unrelated money. And I think that that is particularly interesting about this this provision.
SPEAKER_03And so the the suspension, the notice of suspension comes in. Um Tom, what is the what's the impact on the provider? Now, we've got a lot of different kinds of providers. I think the providers we're really going to focus on for today's conversation are, you know, DC Medicaid providers whose main, whose main or exclusive source of uh payment is DC Medicaid. So talk us through what happens to the provider once the suspension letter is received. What's the impact on the business?
SPEAKER_02Well, I mean, there's not a uniform impact, but let's just say that in in the in the common world, a lot of outpatient mental health is funded through Medicaid payments. Especially, you know, it it just is a lot, it's a big part of it. Medicaid is the major payer. So if this particular business may be, let's say like DC or an area like DC, maybe almost exclusively Medicaid funded. That's part one. Part two is these are not businesses with high margins. So it's not like this is, you know, complex surgeries or something. These things are being paid at by Medicaid as opposed to private pay. So there's not like huge margins out there waiting in accounts. So I think the impact is it effectively closes down operations. Uh there they're not gonna be able to function and pay their staff for long, if they can at all, once they stop getting reimbursements. And, you know, it's so the question is how uh uh you can you require people to continue to work? No, so you're probably not gonna be able to pay. So I think it has a from an operational side a dramatic effect. If two, you simultaneously have gotten some kind of subpoenas or search warrants or otherwise, now how do you pay for your defense for the company level? Uh if you're not getting funds anymore to pay to respond to subpoenas or otherwise, it's a it's a pretty crippling effect, I would say.
SPEAKER_03Absolutely. So the letter comes in, Cliff, and you've you've been through this with clients many, many times. Um what is what does the client, what is the provider um entitled to know about the factual basis for the suspension? What what sort of information is provided? Because as you want to assist the client, the provider in fighting back, you need to know what the basis of the suspension is. But what sort of information is typically provided to the the provider at this point?
SPEAKER_00Yeah. The short answer is very little. The letter that uh that you're referring to, Sarah, is usually uh it includes a one sentence of uh uh an allegation that uh you provided services uh and uh and that uh or you did not provide services and were prepaid, or that you paid someone or compensated someone for a referral. It's a one-liner. Uh, and they are suspending your entire Medicaid business on a one-liner. Uh so for some providers uh that don't get counsel, they tend to read the back of the letter and say, oh, it says that I can appeal and that I can ask for an administrative review. Let me hurry up and do that. Uh unfortunately, that the information that's provided on the letter is insufficient to wage any kind of defense. What you do have to do is you have to request not only an extension of time to respond, but you have to request a copy of the report of investigation. Uh, they sometimes call it an ROI. Uh and sometimes those reports are a little difficult to get because uh various and sundry government officials say, well, it's confidential. We don't want to give you that information. Uh, and of course, every day is a day that you're not being paid. Uh, but in order to mount a defense, you need all the information that is the basis of quote unquote that credible allegation of fraud so that you can do the intensive data work within the provider's information to show that there's insufficient evidence that that particular allegation is fraud. We have an example uh that uh I could talk about uh when we have an opportunity, Sarah.
SPEAKER_03Yeah, we'll we'll we're gonna get to some success stories in in a minute. We'll just let's just walk through the rest of the sort of nuts and bolts of the how this process works. Um, so the you know, the client gets the the notice of suspension. There's very little information on it. What are the avenues, Cliff, um, in DC Medicaid for appealing or otherwise fighting against the suspension? So I believe the first one is going to be um going directly to DC Medicaid. Do you want to talk about that one first?
SPEAKER_00Sure, sure. There is an avenue of an administrative review. Uh the administrative review is an avenue directly to the decision maker, uh, which in DC's case is the Department of Program Integrity. Uh and that review is such that you want to get that a report of investigation. You want to then find out what the basis of this allegation is, and you want to marshal the evidence to show that it is not fraud. It's a mistake, it's uh a uh an incident of independent action by, for example, a CSW, which is otherwise not replicated throughout your organization. Some basis to cut uh the connection between the action and uh the agent. So the first line is this review. The second, and and the review is time sensitive. They say you have 30 days, so you have to ask for an extension in order to really make your case because it's gonna take more than 30 days. But simultaneously, you also have an avenue with the Office of Uh Administrative Hearings, OAH. Uh, and I think it's important to also uh take advantage of that avenue because you can go to the administrative law judge and make your case to that administrative law judge that there is no quote unquote indicia uh of uh of reliability with respect to fraud.
SPEAKER_03Uh and the and and the uh the judge has the ability to make that determination, uh, which could be outcome determinative to the extent they make that with respect to all of the allegations So we've got these two avenues of recourse going doing doing an administrative review back to the essentially the the state Medicaid agency or going through an administrative law judge process.
SPEAKER_00Correct.
SPEAKER_03Um what I mean just sort of bottom line, Cliff, what what are what are the what are the like what's the likelihood of success that a provider is going to be successful on one or both of these avenues?
SPEAKER_00It's uphill. Uh it is it's extremely challenging, but it does require detail. It requires a understanding of how to make the case to break the causal connection of whatever this allegation is and fraud with respect to the provider. Uh and it requires a great deal of detail. And that's in real time at the same time as the provider is not being paid. So uh it is uh it is an it's it's an uphill battle. And again, back to the administrative law judge, the administrative law judge cannot make a determination that there is no fraud or that you can go free. They can make the specific determination that there does not seem to be a credible allegation with respect to this indicia of reliability. So if you can show that it's a mistake, that it is uh some activity that wherein the agency actually got it wrong, the the administrative law judge can make a determination with respect to that specific piece of information. Uh, but that is, again, a lot of detail. Uh and it is a uh extremely time-consuming uh uh process. And uh and and our experience has been very few providers are able to prevail.
SPEAKER_03So, Tom, you're a very experienced criminal defense attorney. And in obviously in federal criminal practice, there's the concept of discovery. If your client is indicted, you get discovery under the federal under the federal rule of criminal procedure 16 and and you know, the all the all the related case law uh such as United States versus Brady. You have a you have a record to fight the case. Now, in this type of situation, there is no right to discovery, as as Cliff has been referring to. Um, you know, from the sort of from your perspective as a as a criminal defense attorney, Tom, and and a um civil defense attorney too, in terms of false claims act matters, um, give me your reaction to trying to fight a payment suspension without discovery, without an entitlement to discovery.
SPEAKER_02Well uh you know, it reminds me a little bit about you know responding to a false claims act before it's out from under seal. You have no rights to discovery. It's a one way street with information, and the only way you get information is by you know getting making it worth the while to the government to share. Reverse proffers, things like that. So you in a lot of these suspensions, you know, the suspension is at the administrative level, the agency level, and then there's usually someone from the AG or someone who you're talking to. And I think at least for my mind, if I'm in this situation, it feels like it's just going to elevate and speed up the clock of trying to get in front of them and saying, let's get a discussion going about what your concerns are and see if we can't get a resolution quickly. I think it just has the effect of speeding up the clock on how you approach your plan for a case. Because otherwise, you know your clients can run out of money. And then there's is there iterative? Now I know it's not in in the Medicaid, but you know, in Medicare, one of the common things to do with payment suspension is to convince them to do not a full payment suspension, partial suspensions of a certain percentage or you know, to a certain degree. So there's there's things that how do you how do you earn some way back into the good graces? The more you can show it's you know, the payer, a lot of times the person receiving it is the entity. If you can show the person responsible for the conduct is a employee or former employee, or someone who's left or has been dealt with separately, and you voluntarily made a disclosure, some other thing, maybe that's you know, there's things you have to try to do to get the discussion to be, I think, in a a more fa you know faster thing. And I think um and going back to a little bit of what you said, uh you know, this is coming, I think, in more into the Medicare. I think in the future we're gonna see it bleed its way when it has effect as well. It is is in the Medicaid on speeding up responses and pressuring defendants. It's gonna get some ground. So even if it's discretionary with the Medicare enforcement.
SPEAKER_03So I think what what the both of you are pointing to is advocacy, right? Cliff, you're talking about advocacy, advocacy with the state Medicaid agency to get information that you're not entitled to under law, you know.
SPEAKER_02You have to get it through the AG, not the agency. I think you're gonna have to get whoever's handling the parallel investigation to be cooperative. This is my prediction.
SPEAKER_00Yeah, well, well, here uh you're you're you're spot on, Sarah, uh advocacy, because here, particularly in DC, you have to make your appeal to the Department of Program integrity. And they may say, well, this is sensitive information, it's an ongoing investigation, we don't want to give it to you. And ultimately, you've got to appeal to them. And sometimes the information comes out drips and drabs, but it's important to remain uh uh vigilant in your advocacy because the the only way to mount a defense is to get all the information that's the basis of that credible allegation of fraud. Now, sometimes you may be able to utilize the Office of Administrative Law Judges to help pull some of that information out to the extent that uh because you you you you you can't make a defense without it. Uh, but the bottom line is you've got to get that information to have any chance of uh possibility of terminating the suspension.
SPEAKER_02I'm just curious. Um, you know, a lot of times in the criminal realm, when it's this kind of an ongoing investigative concerns, and and Sarah certainly knows this, you'll have attorney's eyes only type meetings and disclosures. Have you had any luck with things like that where you say, look, I understand you have an ongoing investigation. We at least let me, you know, attorney's eyes only, let me see what's happening, learn a little bit about it so we can at least address it.
SPEAKER_00That has been a request and it's been denied. That's funny. So uh, but but I I will say that sometimes it takes you know five, six, seven months to get this information, which again in real time means that you can't even mount your case until you get this information.
SPEAKER_03So and that that sort of that takes us into the next sort of subtopic here. So you know, the what's going on is you have a payment suspension at the same time as there is there is an investigation, typically criminal investigation by the Mufuku, Medicaid fraud control unit. Okay, so you have these two of these two processes going on. One is fairly static, the suspension, and one is dynamic, the investigation. And so the investigation, because what we've, what Cliff and I have observed in our many representations in this area is because the initial standard to impose a payment suspension, the credible allegation of fraud, is so low. It's pretty much the lowest burden of proof that I've ever encountered in the American legal system. You know, as Tom was talking about before, it's not probable cause, it's not, it's not preponderance of the evidence, it's definitely not proof beyond a reasonable doubt. It's not any of those standards, it's something else.
SPEAKER_02It's akin to like a reasonable suspicion kind of thing, like a traffic stop. I don't know what I'm saying.
SPEAKER_03What I would analogize it to in the criminal world is like the threshold for issuance of a criminal grand jury subpoena. There's really, it's a really, really, really low standard. So what happens is as you know, Cliff is talking about, sometimes it takes six or seven meetings or phone calls with the DC Medicaid agency to get those drips and drabs of information. And so where I'm going with this is that because that standard to initiate the payment suspension is so low, and it doesn't have to be reliable, it just has to be a credible allegation of fraud, which is frankly, in my opinion, uh the m the lowest standard I've ever seen.
SPEAKER_02See, one could argue that a simple filing of a QITAM related. It's really mushy could be sufficient. The allegations of complaint.
SPEAKER_03Yeah, it's well, but but but a key TAM, the filing of a complaint in federal court, Tom obviously is subject to the rules of ethics that govern attorneys. Right. So you have the attorney who files that complaint has to have a good faith basis to file it, right?
SPEAKER_02A good faith basis could requirement.
SPEAKER_03But we're not talking about we're not talking about attorneys and ethics.
SPEAKER_02No, I'm sure.
SPEAKER_03We're talking about, as Cliff referred to, like one hotline complaint.
SPEAKER_00A hotline complaint from somebody that you don't even know.
SPEAKER_02It could be your competitor. It could be your competitor, it could shut you down, basically.
SPEAKER_03Absolutely. It could be your competitor, it could be one law enforcement interview with a beneficiary who perhaps, let's say, is disgruntled for some reason. It can be a very, very, very slender thread. So Cliff is talking about, you know, the question is, well, how do you get the information out of the DC Medicaid agency so you can actually mount your defense against the suspension? As these two processes are playing out, the static payment suspension and the dynamic investigation. We don't get to see this as defense attorneys, but as a former prosecutor, I know this is happening. Sometimes those allegations, those that credible allegation of fraud turns out to be nothing, right? They the agents continue to investigate, and what they thought was initially a problematic fraud situation turns out to be, you know, nothing, nothing that they can actually be actionable. It's not really fraud, it's something else. It's a misunderstanding, it's a misinterpretation, whatever. And so while Cliff and I are pestering the DC Medicaid agency to give us the report of interview, the DC Medicaid agency is aware to some degree of the progress or lack thereof of the criminal investigation. And if, and you know, it's sort of like this. If the investigation is like going down and it's probably going to be dismissed, then Cliff and I have a better chance of getting that information that underlies the credible, the credible allegation of fraud, and that allows us to fight back against the suspension. Now, let me just talk, let me just touch on this. And Cliff, let me let me turn this question to you. Um how do these how often do these payment suspensions need to be re-opt? And how does that work? And how long does how long do these payment suspensions typically stay in place?
SPEAKER_00Yeah, well, that's an interesting question because uh, as you uh mentioned, uh the state is required, once they do a payment suspension, to refer it to the Mufuku to do this investigation. Uh and then by regulation, they are supposed to request from the MFU every 90 days whether or not that investigation is ongoing. Uh and the Mafuku needs to then respond. And to the extent it is not ongoing, then by regulation, uh there is no longer a credible allegation of fraud. Now, the if it's just a credible allegation, you would think that the Mufuku, it might take them quite a long time to conduct this investigation because there's so little information in the first place, uh, which fundamentally means that the provider really has to conduct a lot of the investigation and bring it to their attention. For example, you mentioned if it's a a uh recipient that says, you know, I didn't get the services that I should have gotten when uh my CSW said it was an hour. Well, they may be thinking of a CSW from another agency, or they may not be clear about uh what agency the CSW's uh for. There's a lot of gray areas that could be the basis of a credible allegation, but not fraud. And so ultimately it becomes incumbent upon the provider to do that investigation and bring that information to their attention because the Mufuku may take months, if not years, to uncover that. There is no timing that they have to complete the investigation. There's only a timing with respect to the continuation of the investigation. Uh, and so continuation of the investigation is not a quote unquote good thing for the provider, because in many instances the agency will say, I cannot lift a suspension as long as there's an ongoing investigation. Uh and so that's a loop that uh is hard to get out of.
SPEAKER_03And that's where the advocacy comes into place to break that loop. Uh, Tom, you were saying?
SPEAKER_02Yeah, I was just gonna just for the sake of just closing one loop, you know, the ongoing investigation is important for another reason, which is for anyone hearing this thinking, well, I would just file a public information or FOIA request, there's an exemption for ongoing investigations built into FOIA. So there that's not another way that path is closed down as well to getting documents.
SPEAKER_03That's right. Okay, let's talk about some success stories, Clef. Um, give give our listeners uh some examples, obviously, no client names, of course, but some examples of um success stories you've had in breaking breaking this loop, so to speak, and lifting or modifying a payment suspension.
SPEAKER_00Well, success is highly dependent on getting all the information that you can from the agency with respect to uh their report on investigation. What is the basis of the credible allegation? You've got to get that information, you've got to go then to your files as a provider and be able to explain away that allegation to show that it's some kind of mistake, some kind of uh a misinterpretation by the person uh that is providing that allegation. In one instance, we found uh that the agency conducted an audit. Uh and the audit came up with a lack of documents. The there was uh a lack of the uh the uh the the initial document with respect to uh you know the the the uh the the provider's determinations of the illness in in the instance or or the the uh the the actual documents around uh the treatment plan. Uh and so in this particular audit, they could not find the treatment plan. They could not find the documents that are necessary to bill, and then they made a determination because they could not find the documents that the billing was fraudulent. Well, what we had to do was to show them that the audit was not did not appropriately access the information that was in the provider's files. Uh and if they had, they would have found all of the data which they said were not there. Uh and so our ability to show that data, to show that indeed, yes, we actually had the treatment plan and it was contemporary made uh and dated and appropriately signed and provide all of that information so that we can show that the auditor was mistaken. And in that instance, the one instance, at least one instance when we were successful, it took nine months to actually marshal all of that data, provide all of that information, and then get the agency to make a decision to terminate the suspension. And when they did, what they said is we will terminate the suspension with respect to ongoing uh billing, but we're gonna keep the suspension for accounts receivables until we we uh see if your compliance program, which you are saying you are implementing, is actually operating. And we want to see you report to us about your improved compliance program, and then we'll lift the other part of the suspension with respect to your receivables. So, in in that instance, we got a partial lifting of the suspension until we were able uh to effectively and affirmatively show that they had a quote unquote effective compliance program uh to enable to get the receivables. Uh and in most other instances, what what has happened is the provider has just run out of money.
SPEAKER_03So you mentioned compliance. So, you know, with the time with the time we have uh remaining on our on our podcast, let's talk about. Um, I'm gonna turn to you first, Tom. So, you know, the objective here for providers, uh as Cliff and I always tell our clients, is you want to avoid suspension. You want to do everything you can to prevent the suspension from happening in the first place, because as we've just walked through, the the process is very, very government, pro-government, um, and there are very limited avenues for res recourse for the provider. So, Tom, what what can Medicaid providers do to prevent suspension?
SPEAKER_02Well, I think uh a couple things I would highlight. And I'm sure there's a lot of them, but I'll just highlight a couple. One is uh I think know yourself how you look on paper. And by on paper I mean in the digits. Are you the single biggest performer of a particular service in the entire region? Are you number two, number three? Do you have what does your data show when the government looks at your data? And if you, for instance, if you if there's a particular, let's just say medic medicine, and it and this is the highest reimbursed medicine, and you prescribe more of the highest reimbursed medicine than every single other provider similar to you in the you're probably gonna get attention. So knowing if you have an indicator about your business that makes you stand out. That's number one. Number two is audits are the wolves in sheep's clothing. Take the audits very seriously with an eye towards someone else looking at the results of this and what you say and how you respond and what you provide. And if your response to respond to an audit is this could incriminate me and show that we had somebody engaging in falsifying records or not completing records, or we have a major overpayment, uh, take a careful look at how you respond and be maybe proactive and do a different type of response. And number three, uh actively, regularly do voluntary repayments and voluntary disclosures. Stay on top of them. If you show a pattern of I'm, you know, every time we find an error by your self-auditing, your self-control, constantly correcting the records, getting the money back that you're if you think there's an overpayment, it shows that you are showing a conscientious approach to billing. And I think that will make play a difference in a decision ultimately on if they think there's a credible allegation of fraud, if this is a if they look at it and they see this is a provider who regularly corrects and audits and refunds and does repayments. I think that goes in and certainly gives you ammunition if you have to advocate later on. So those are those are my big three.
SPEAKER_03All right, great. And Cliff, to let's uh last question to you before we wrap up. What can Medicaid providers do proactively to prevent suspension?
SPEAKER_00Same option. Yeah, yeah. No, I think uh Tom is right. Um I I agree with him a hundred percent. I just amplify one of them uh audits. Uh, make sure you take it seriously and you have staff to engage with the auditor, uh, make sure you understand uh what the exit conference is saying, uh, and so that you can respond to whatever the findings are proactively, because that audit is going to be the basis of some kind of action on the part of the agency. Uh, and so you want to get in front of that. Uh, I'd say also uh back to compliance. I'd say that no matter how big the provider is or how small the provider is, having an quote unquote an effective compliance program where you've got somebody who's making sure everybody is following the rules. Uh, and that when a new rule comes out, you can have a committee, that you've got folks to say, how are we going to make sure everybody in our organization understands what the rules of the role are and we're following them? Uh, and so that when things occur, like there is a miss billing, or there is a uh uh uh an instance where uh a CSW is actually billing inappropriately, that you can smoke those things out uh and you can request that those payments uh be retracted uh and that you're effectively becoming uh a fiduciary on uh from the agency, because that's one the uh effectively what they're what they're looking for. I would also say to the extent that you can proactively involve yourself in any kind of self-audit protocols that, for example, the Department of Uh uh integrity has uh so that you can demonstrate to them your compliance program. Uh, it's an effective uh way to uh have conversations with the agency so that they understand that you have compliance uh and that uh you are effectively utilizing it. You know that compliance is not an ensure the right result, but it does show that you are uh you are managing the funds and you're taking your management of the funds uh seriously. And I think that's the important um uh message to communicate to the state.
SPEAKER_03All right. Well, terrific. Well, thank you very much, Cliff Barnes. Thank you very much, Tom Barnard. Really appreciate your participation in today's AHLA podcast. And thank you to all of the audience members who tuned in and made it to the end of this podcast. If you have any specific questions about your company or your particular situation, please feel free to contact any of us directly via our firm's uh website information. Thank you.
SPEAKER_00Thank you. Thank you.
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