U.S. Sens. Tom Udall and Martin Heinrich, and U.S. Reps. Ben Ray Luján and Michelle Lujan Grisham wrote a letter to U.S. Health and Human Services Secretary Sylvia Burwell requesting increased oversight of New Mexico Human Services Department (HSD) to ensure New Mexicans in greatest need of behavioral health services are able to access care.
In 2013, HSD suspended Medicaid payments to 15 nonprofit behavioral health providers due to so-called "credible allegations of fraud." This led to the closure and eventual replacement of 12 behavioral health providers with Arizona-based providers, limiting access to behavioral health services for many New Mexicans with serious mental illness and substance abuse disorders.
"We fully support the need to curb waste, fraud, and abuse in Medicare, Medicaid and other health care programs. However, we are concerned that several irregularities surrounding HSD's decision to suspend payments have undermined the legitimacy of its audit process," wrote the lawmakers. "The purpose of federal oversight is to ensure that states have effective processes in place for determining whether allegations of fraud are credible, and serious questions remain as to whether HSD has such processes in place."
A copy of the letter is available below or HERE:
Dear Secretary Burwell:
Enclosed please find a copy of a letter from New Mexico Auditor Hector Balderas outlining serious concerns with last year's sudden disruption of a vast majority of our state's behavioral health services, which was primarily based on a report that had not uncovered credible allegations of fraud.
As you are aware, on June 24, 2013, the New Mexico Human Services Department (HSD) suspended Medicaid payments to 15 nonprofit behavioral health providers due to so-called "credible allegations of fraud." This led to the closure and eventual replacement of 12 behavioral health providers with Arizona-based providers. These providers accounted for 87 percent of the state's behavioral health services, providing care for 88,000 New Mexicans, including 30,000 Medicaid beneficiaries. The transition was so precipitous and far reaching that it jeopardized services to some of the most vulnerable New Mexicans-those with serious mental illness and substance abuse disorders. Considering that New Mexico is a large, rural, poor, minority majority, multilingual state with an already weak safety net, such an additional disruption to a system with access challenges cannot be allowed to continue.
We fully support the need to curb waste, fraud, and abuse in Medicare, Medicaid and other health care programs. However, we are concerned that several irregularities surrounding HSD's decision to suspend payments have undermined the legitimacy of its audit process. The purpose of federal oversight is to ensure that states have effective processes in place for determining whether allegations of fraud are credible, and serious questions remain as to whether HSD has such processes in place.
For example, contrary to its own official procedures, HSD's Program Integrity Unit (PIU) did not conduct its own investigation prior to referring all 15 allegations to the New Mexico Attorney General's Medicaid Fraud Control Unit (MFCU). By HSD's own admission, its PIU "has never performed, nor is it capable of performing, a program integrity audit involving 15 large providers." This casts doubt on whether the report-which solely relied on extrapolation methodology from an outside contractor-was a sufficient basis for immediate payment suspensions.
The manner in which HSD imposed payment suspensions against providers constituted a de facto termination from the state's Medicaid program without any meaningful due process. Moreover, there does not appear to be a limiting principle to this open-ended authority. If a state can establish a credible allegation of fraud based on a haphazard determination of potential overbilling, there is nothing preventing it from shutting down any statewide network of safety net providers based on what could turn out to be baseless allegations.
We are also concerned about the prospects of continued disruption in the delivery of critical behavioral health services. We have heard from numerous constituents including families, consumers, advocates and providers about a frayed behavioral health system. According to a June 2014 survey, 83 percent of respondents believed that New Mexico's behavioral health system was worse than it was one year ago.
Evidence supporting that concern was reported in a July 19, 2014 Las Cruces Sun-News article, which stated that La Frontera behavioral health center in Las Cruces reported a 22 percent workforce reduction compared to its pre-suspension staffing levels. According to this article, high stress and poor work conditions are progressively deteriorating staff morale. Combined with staff reductions, abrupt management changes have resulted in administrative burdens that have negatively impacted services to our most vulnerable citizens, including those who may be suffering from suicidal ideation, schizophrenia and bipolar disorder.
Medicaid is a state-federal partnership, and CMS' effective oversight is particularly critical in this situation. We appreciated CMS' September 2013 site visit, which identified several issues that negatively affected access to care. Unfortunately, we are concerned that HSD has significantly hindered CMS' ability to conduct proper oversight by providing late, incomplete and inaccurate information. As a result, we do not yet know the full extent of barriers New Mexicans face in accessing the behavioral health services they need.
Given the troubling circumstances outlined above, we respectfully ask that HHS vigorously increase oversight of HSD's process for, and actions subsequent to its decision to suspend provider payments due to "credible allegations of fraud." We must ensure that New Mexicans in greatest need of behavioral health services are able to access such care, especially with federal public dollars entrusted for this purpose.
In addition, we question whether CMS has oversight procedures in place to prevent other states from experiencing the unacceptable fraying of the behavioral health safety net that New Mexico now faces. From the CMS-recommended auditor's flawed extrapolation process, to the lack of transparency and interruption of services in our state, this partnership has proven unacceptably weak. We urge CMS to take undertake stronger regulatory oversight measures to prevent this type of situation from happening again. Further, we look forward to hearing about the process improvements CMS instituted to prevent such an outcome in other states, as well as improved oversight and capacity improvements for New Mexico.
Finally, we question whether CMS has exercised sufficient oversight in ensuring continuity of care for individuals who rely on New Mexico's behavioral health system. We continue to hear reports of lack of access to services for this very vulnerable population and want to work with you to ensure that anyone who needs care gets it without delay.
Thank you for your commitment to addressing this important issue and we look forward to working with you as we explore all available regulatory and legislative options to prevent something like this from happening again in the future.
United States Senator
United States Senator
Ben Ray Luján
United States Representative
Michelle Lujan Grisham
United States Representative