Sen. Mary Kay Papen: No legal barrier to making use of local providers (LC Sun)

Sen. Mary Kay Papen: No legal barrier to making use of local providers

By Sen. Mary Kay Papen

Guest column

Posted:   04/27/2015 12:45:55 PM MDT

In July 2013, the Human Services Department (HSD) could have lifted the pay suspension of any New Mexico behavioral health provider that HSD had referred to the attorney general for investigation based on a “credible allegation of fraud.”

Federal law (42 C.F.R. §455.23) allows a state to continue using and paying a Medicaid provider that is under investigation if there are other ways to more effectively or quickly protect Medicaid funds, or if access to services would be jeopardized because the provider is the sole source of essential specialized services in the community, or if the provider serves a large number of Medicaid recipients in a medically underserved area or if the state determines that suspending payments to a provider is not in the best interests of the Medicaid program. In July 2013, HSD wasn’t interested in lifting pay suspensions for most of the referred providers because it had already made arrangements to replace them with Arizona agencies.

Flash forward 21 months, and Turquoise Health and Wellness, an Arizona provider that served the southeastern part of the state, has gone home. La Frontera, another Arizona provider that served southern New Mexico, is also headed back to Arizona. A recent assessment by an independent consultant states that La Frontera currently has 3,795 clients. The New Mexico providers it replaced have advised that they served approximately 8,100 clients before La Frontera took over.

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