(About three weeks after my last post about what its like to be a billing provider with North Carolina Medicaid and specifically Wellcare, the audit has been resolved. Once Wellcare re-reviewed the information we submitted to the Administration Law Judge (ALJ), they decided they wanted to settle for $437.00 instead of their former overpayment request of $75,000 (originally $150,000). As part of the settlement, they required me to keep the matter confidential and for me to be part of an “educational” meeting where their auditors would tell me what I did wrong. How AMUSING! I DECLINED the settlement because no way am I going away and paying all of the legal fees ($35,000 now) and keeping quiet about how Wellcare’s auditors got it SO wrong. So, they agreed to a post-appeal. Post appeal is sort of like a review of the information with a letter for demand of payment. At this point, I agreed to that but they had not shared with me what the claims were that they were demanding as overpayment ($437.00). Earlier this week I received the official letter with the claims that were considered overpayment. Two of the claims were the same supervision issue which they said that they were demanding overpayment because I co-signed an assistant’s notes. The affidavit from our professional Board stated that co-signature was allowable and NC Medicaid says its allowed. In fact, the auditors removed the rest of the claims dealing with supervision but left two . For what reason? To still look like they found “fraudulent claims”? I guess. Another claim they continued to demand overpayment was for a therapist whose last name had changed. The auditors couldn’t connect the dots that the license number, first name, and address was the same,
My follow-up letter, along with my check to Wellcare /Centene was as follows:
To whom this may concern,
I am deeply concerned with the lack of knowledge that was communicated during my recent Medicaid /Wellcare audit. The auditors did not show competence in understanding the rules governing providers or the North Carolina Board of Occupational Therapy. The information my group shared with the Wellcare Auditors was repeatedly ignored and misconstrued as they continued to make allegations of my “fraudulent” claims . The auditors went so far as to attempt to look up occupational therapy assistant’s information on the NC Board of Occupational Therapy’s website. When they could not find that information, they claimed no one was supervised or had a license. The Auditors’ scope of reach is not to act like a profession’s Board. The Occupational Therapy Board manages and ensures that all practitioners are licensed. The O.T. Board governs supervision. Your Auditors asked for detailed supervision notes. This, of course, is never acceptable because supervision notes include information regarding patients with various health plans. This would be considered PHI.
When your Auditors couldn’t get detailed supervision notes, they began asserting that the claims were not allowed because an occupational therapist other than the supervisor had co-signed the treatment notes. Again, when I provided information from BOTH NC MEDICAID as well as from the NC BOARD OF OCCUPATIONAL THERAPY stating that only the signature of the rendering provider was needed and that co-signatures were allowable, the Auditors continued to demand overpayment. They recited precisely the same documents, but they MISCONSTRUED the information. At this point, they were demanding $75,000. The co-signature of notes “issue” constituted 98% of that amount. I was served with a summary judgment when I disagreed to pay for something that was not owed. Of course, I had to seek legal counsel to restate all of the information previously provided to the Auditors. As part of the legal appeal, we submitted an Affidavit from the North Carolina Occupational Therapy Board restating that the Auditors did not understand the supervision rule correctly. This process of back and forth resulted in Wellcare making a post appeal stating that I owe $437.73. Two of the claims still involve the co-signature “issue” so I know that the Auditors still do not understand NC Occupational Therapy rules nor NC Medicaid rules.
Along the way, I am on the hook for $35,000 in legal fees for this matter. The information that was provided at the beginning of the audit is exactly the same as what was provided at the end of the audit. This makes me believe that either your auditors are completely incapable or that this was a calculated plan to make me “give up” and pay your overpayment demands. Your audit was not only unethical but also was financially harassing toward me. This is why you are losing provider groups. I will be telling my story to anyone that will listen because this is completely unacceptable and not what I signed up for when agreeing to provide occupational therapy services to children with Medicaid. Shame on you Wellcare for treating YOUR providers like this.
Sincerely,
Stephanie Wick
Did I win? Well, not really. Financially its a complete loss. But I think that is the game that Wellcare is playing with its providers. Its not just me. Check out a recent blog from Knicole Emmanuel about a similar situation but with a lot more $ at stake. Thank you to Carrie Meigs and her team at Michael Best Law Firm for their excellent support.
