By Dave Ranney
KHI News Service
TOPEKA, Dec. 15
Six months ago, state officials were dreading the prospect of having to refund tens of millions of dollars in federal aid.
They”d already agreed to give back $32.4 million after federal auditors questioned how Kansas had billed Medicaid for services for school children.
More audits were on the way, prompting some to warn the toll could top $200 million.
No one is saying that now.
“I think we”re past that, I really do,” said Barb Langner, an associate professor at the University of Kansas School of Nursing.
Langner is leading a Kansas Health Policy Authority-created work group that”s been coordinating the state”s response to the audits.
“It seems we have a better working relationship with regional CMS (Center for Medicare and Medicaid Services) office in Kansas City,” she said. “We”ve been meeting with them about every month or so, talking through the issues.”
There”s no way to know how much more the state will have to give back, Langner said, but most of the audits” “hard findings”
those not in dispute
have been settled.
The remaining audit findings, she said, are not as clear and may or may not result in a loss of federal funds.
“If you wanted to, you could rack up a laundry list of liabilities that would be a mile long,” Langner said. “But it”s our impression that CMS is most interested in our being in compliance with our state plan, and that”s the road we”re on. We”ve made it clear to them that we”re serious, we want these issues resolved so we can move on.”
Langner said the Kansas Health Policy Authority and the Department of Social and Rehabilitation Services have submitted to CMS needed changes to the state”s Medicaid plan.
“Some have been approved already and some are still in the response-to-question phase,” she said. “We”re aiming for a July 1 implementation.”
So far, the audits have taken the state
Department of Social and Rehabilitation Services, namely
to task for the way Medicaid was billed for:
*
School-based health services for children with special needs;
*
Mental health services for children in the state”s foster-care and adoption networks;
*
Case management services.
The audits were by the Office of Inspector Generator within the U.S. Department of Health and Human Services.
Six of the
audits
have been made public. Five of the six focused on school-based services provided between 1998 and 2003; the sixth questions the state”s formula for figuring how much to bill Medicaid for administrative services at community mental health centers.
Other audits
there isn”t an exact count
are in various stages of completion and have not been made public.
But SRS officials have said that an ongoing audit of its mental health services for children in foster care prompted recent changes in how residential facilities are licensed and how they will be paid.
Another audit, Langner said, is driving SRS and health authority reviews of how the state bills Medicaid for case management services.
“We”re making good progress,” Langner said.
CMS Regional Director Tom Lenz declined to agree or disagree with Langner”s assessment.
The processes for resolving the issues, he said, do not lend themselves to quick or simple conclusions.
“The audit recommendations identified program weaknesses that must be addressed by the state,” Lenz wrote in an e-mail to KHI News Service.
Some of the audits, he said, recommend that Kansas figure out how much it owes for errors that occurred before or after the years covered by the audits.
“Resolution of this type of audit recommendation can be very complex and may take some time to resolve,” Lenz wrote.
Still, state officials say they”re optimistic.
“I can tell you that in my dealings with CMS, they appear pleased,” health policy authority Executive Director Marci Nielsen said during the authority”s Dec. 12 meeting.
“I think we”ve shown we”re serious about getting these things resolved and showing that we can be trusted,” Nielsen said.
Neither Nielsen nor Langner deny that mistakes were made.
School districts, for example, routinely billed Medicaid for 12 months worth of services when regulations allow no more than nine months. Some used the wrong inflation rates
educational instead of medical
in their calculations.
Others had trouble proving that services were, in fact, provided three to eight years ago.
“We”ve conceded that, yes, record keeping wasn”t as stringent as it might have been,” Langner said. “But a lot of this comes down to how much the bookkeeping verged from what the feds wanted.”
Billing rules, she said, weren”t always clearly understood.
Langner said the audits have not uncovered malfeasance.
“I don”t think anyone acted in bad faith,” she said. “I don”t think this has ever been about a child not getting a service he or she needed. It”s more about accountability, record keeping.”
Kansas isn”t the only state dealing with CMS audits.
“Oh, no,” Langner said. “This is going on all over the country.”
But finding out how other states have fared isn”t easy.
“These (audits) are being done one state at a time with no clear rules or guidelines, which makes it very hard to keep track of how much of it is happening , under what circumstances and, sometimes, even why its happening,” said Allen Weil, executive director at the National Academy for State Health Policy in Portland, Maine.
“Any individual state, including Kansas, is at a real disadvantage because it can”t say to CMS, “Well, it was like this here and like that there, so treat us the same,”” Weil said. “There are no standards by which to judge a lot of this.”
Weil said the audits are driven by the federal government”s desire to cut its health costs and to rein in certain states.
“There”s an element of arm-twisting going on here,” he said.
Dave Ranney is a staff writer for KHI News Service, which specializes in coverage of health issues facing Kansans. He can be reached at
dranney@khi.org
or at 785-233-5443, ext. 128.