An audit of the community stabilization program found that a service budgeted at $12.5 million last fiscal year was billed $88.5 million by vendors under state contracts with six companies of managed care. In the new fiscal year, which began July 1, insurers have already spent $28.9 million on authorized services for $21.2 million.
The Department of Medical Assistance Services, the state office of Medicaid, said it had referred the matter to the Attorney General’s Medicaid Fraud Enforcement Unit, which works with the FBI and Henrico Police to investigate the alleged misuse of a service designed to bridge the gap between people. in crisis and community care.
“This is really a central problem in Virginia,” Tammy Whitlock, deputy director of complex care services, told the Senate Finance and Appropriations Committee on Wednesday.
Whitlock said the department audits use of the service and refers potential abuses to the attorney general’s Medicaid Fraud Unit. She said it would likely result in “financial withdrawals which will return the funds to the Commonwealth” and the managed care companies overseeing the service.
A spokesman for Attorney General Jason Miyares had no comment on the investigation.
The department also instituted a new requirement, effective Sept. 1, for providers to receive authorization from managed care companies before providing the service and charging for it. It also hosted a training session for 250 vendors on August 29 to review the new licensing requirement.
“It’s definitely a problem we’ve seen and we need to fix it,” Whitlock said.
The ministry said 61 vendors – or about 18% of the 348 participating vendors – accounted for 80% of the cost of the service in the fiscal year ended June 30 and the first two months of that fiscal year. These providers billed nearly $94 million of the $117.4 million spent on the service.
Twenty-seven of those vendors each billed more than $1 million in six months, the department said.
The central Virginia region showed a “disproportionately high density of providers and usage, with four to five providers driving usage,” Whitlock said. The department did not name any of the suppliers in its presentation to the committee.
The problem has come as no surprise to insurance companies that administer care for the state. Doug Gray, director of the Virginia Association of Health Plans, said his companies recommended that the state require providers receive pre-approval before providing the service, based on similar experiences with other health services. community behavioral health in previous years.
The state did not require prior permission, Gray said. “Vendors went wild with it.”
“The good news is that they are trying to get the situation under control,” he said.
Whitlock said the Medicaid office became aware of the problem during an audit of the service in April. “We didn’t act as quickly as I thought we should have,” she acknowledged.
The department is reviewing all major services to spot any other unusual “usability anomalies” by the end of the year. It also begins a process of reviewing new services as they are implemented, including monitoring plans and thresholds “for further analysis and intervention”.
The Community Stabilization Service is part of a larger initiative, known as BRAVO, or Behavioral Health Redesign for Access, Value and Outcomes, to improve services provided by Medicaid to people with behavioral health needs.
Community stabilization is intended to help people after experiencing a behavioral health crisis as a transition either to a lower level service that is not immediately available or to a higher level of care.
“We want to see some growth [in the service]”, Whitlock said. “There’s pent-up demand there…but we want it to be an appropriate use, and clearly $88 million isn’t appropriate.”
The local and regional community services boards are not involved in the administration of the service, but they have every interest, as providers, in ensuring its viability in order to help people recovering from psychiatric crises.
“It is unfortunate that this has happened … as it may impact the availability of service for those who need it,” said Jennifer Faison, executive director of the Virginia Association of Community Services Boards. “It’s an essential service.”