There are still a lot of questions about the New Mexico Human Services Department's abrupt halt of Medicaid funding to 15 behavioral health providers and the state's contracts with Arizona firms to take over provider management.
Here's some of what we do know.
1. The Human Services Department (HSD) halted funding for 15 behavioral health providers who provide services to 30,000 clients in New Mexico in response to allegations of Medicaid fraud. The managed care organization that oversees behavioral health services in New Mexico, Optum Health installed a new software system to detect fraud. When that system sent up red flags, the state ordered an audit.
2. The audit findings set off alarm bells that the providers had allegedly incorrectly billed Medicaid for $36-million. The details of the audit have not been released to the public but some information has been provided to at least one media outlet.
3. The auditing firm PCG performed the $3.2-million audit through an emergency, no-bid contract with the state. PCG has also contracted with the state to manage the New Mexico Health Insurance Exchange. That contract is for almost $4-million.
4. Behavioral health, or mental health, is achieved when people experience a state of well-being and are free of depression and anxiety disorders. Behavioral health services include things like psychiatric care, medication, and various forms of one-on-one and group therapy. Patients experiencing things like addiction, schizophrenia, autism, sexual abuse, and a wide range of other issues and conditions can seek behavioral health services.
5. Fifteen behavioral health providers were audited. At least 12 face take-over by Arizona firms.
- Teambuilders, Inc. - 22 counties
- Partners In Wellness, Inc. - Los Lunas
- Presbyterian Medical Services, Inc. - 9 counties
- Hogares, Inc. - 5 counties
- Youth Development, Inc. - Albuquerque
- Pathways, Inc. - Albuquerque metro area
- Border Area Mental Health Services, Inc. - Silver City
- Counseling Associates, Inc. - Roswell
- Families and Youth, Inc. - Las Cruces
- Southwest Counseling Center - Las Cruces
- The Counseling Center - Alamogordo
- Valencia Counseling Service - Los Lunas
- Southern New Mexico Human Development - Anthony and Sunland Park
- Easter Seals El Mirador - Santa Fe and Alcalde
- Service Organization for Youth, Inc. - Raton
6. Five Arizona nonprofits who have contracted with New Mexico to take over management of local providers.
- Agave Health, Inc. - $7.1 million
- Valle del Sol, LLC - $2 million
- La Frontera, Inc. - $4 million
- Southwest Network, Inc. - $2 million
- Turquoise Health and Wellness - $2 million
7. The Arizona providers will continue to manage organizations in New Mexico. Contracts go through the end of 2013, but an official of Governor Susana Martinez said earlier this month that the take over is permanent.
8. Many of the New Mexico providers say they have not been given details about what fraud they are accused of committing. The say the funding freeze and new management constitute a violation of due process. They argue the state's actions are damaging to relationships with clients and, in some cases, to the financial solvency of entire organizations.
9. Several of the local providers who were not granted good cause exemptions and did not have any of their funding restored filed a lawsuit against the state. So far, they have been unsuccessful at getting their funding restored.
10. Officials in Governor Susana Martinez's administration say they have a responsibility under the Affordable Care Act to find and prevent Medicaid fraud. Many of the allegations in the audit are egregious.
11. Lawmakers have delayed a $10 million fund transfer from the state of New Mexico to the Arizona contractors. A hearing was held August 21st in Chama at which legislators voted not to endorse the transfer. The vote did not halt the transfer.
12. Members of New Mexico's Congressional delegation have requested that officials from the US Health and Human Services Department hold a public hearing in New Mexico. Senators Tom Udall (D) and Martin Heinrich (D) and Representatives Ben Ray Lujan (D) and Michelle Lujan Grisham (D) wrote a letter to HHS Secretary Kathleen Sebelius on August 14th asking that she set up the public forum within two weeks. No date has yet been set.