Santa Fe New Mexican: Our view: Legislation would protect patients, Medicaid program

Laws often resemble the proverbial barn door, which is shut after the horses have run away or been stolen. Many statutes address a crisis that is already over. Even so, it’s important to prevent repeat mistakes, which is the intent of a federal bill supported by all of the Democrats in New Mexico’s congressional delegation.

They want to make sure that the most vulnerable patients — people who need help with drug addiction or mental health issues — can’t lose their care because of bureaucratic overreach. If the legislation, called the Medicaid Program Integrity Act of 2016, passes and is signed into law, a shakeup such as the one that rocked New Mexico behavioral health service providers in 2013 won’t happen again.

Remember, that’s when the state Human Services Department took away funding from 15 behavioral health providers, citing what it called “credible allegations of fraud.” The actions by agencies caring for Medicaid behavioral health patients were so egregious that the only remedy, said state officials, was to strip funding. Immediately, with no opportunity to appeal. Arizona contractors were hired to offer the services instead.

After all that commotion and disruption of service, it turned out the state officials had overstated the case. Recently, New Mexico’s Attorney General Hector Balderas announced that his investigation showed that in the case of 13 providers, no fraud existed.

The new legislation would clarify when and how the state can remove Medicaid funding from providers. At present, federal law allows states to strip funding for “credible allegations of fraud,” giving the state wide discretion in doing so. The trouble with that approach, however, is there is no check against unfounded allegations. Providers are deemed guilty based on the decisions of bureaucrats.

Several of the service providers caught up in the New Mexico crisis have gone out of business; others paid settlements so they could keep operating — this, even though they still claimed to be innocent of fraud charges. They had little recourse under current law.

With the proposed legislation, Medicaid agencies would have to consult with the state attorney general before payments could be stopped. States also would have to consider the impact on the people who use the services. States also would have to stop suspension of payments once the investigation is concluded. Importantly, there would be provisions for an appeals process. Providers would have a chance to prove innocence, something they previously lacked. The National Council for Behavioral Health has endorsed the federal legislation.

We are glad to see members of New Mexico’s congressional delegation — Sens. Martin Heinrich and Tom Udall, and Reps. Ben Ray Luján and Michelle Lujan Grisham — step up to protect people who depend on these essential services. Patients have suffered because the system took a body blow. Entrepreneurs lost their businesses, and medical workers lost jobs.

The contracts were shifted to Arizona providers, sending New Mexico dollars out of state and leaving too many patients without proper care. That shift didn’t work, either; at least one lawsuit has resulted, with an Arizona company alleging that it lost millions of dollars and other providers have left the state. (La Frontera is suing OptumHealth New Mexico, the former overseer of Medicaid behavioral health services and its parent companies, alleging fraud and breach of contract, among the claims.)

By setting standards for how contracts can be terminated and payments stopped, the law would protect taxpayer dollars as well as patients. Congress should pass this sensible legislation so that patients in other states don’t face similar upheavals in their care.