Autism Review

1. MDs practicing defensive medicine and increasingly using 'late preterm' cesarean delivery.
2. Couples opting for fertility treatments that inevitably lead to increased incidence of twin/triple/quad pregnancies (and sometimes more).
3. Poor prenatal care among illegal immigrants and undocumented aliens who do not have health insurance.
4. Poor prenatal health care among groups who DO have access to Medicaid.
5. Smoking, obesity, teenage pregnancy, and other lifestyle factors.

Emergency action is necessary for the preservation of the public health and general welfare to immediately conform the Commissioner's regulations to chapter 460 of the Laws of 2011, and thereby ensure that such regulations are in effect on February 14, 2012, the effective date of such law, to implement the new practice and supervision provisions consistent with statutory requirements, EXCEPT FOR WHERE IT MESSES UP OUR ABILITY TO GET MEDICAID REIMBURSEMENT, IN WHICH CASE NOTHING IS A GREATER EMERGENCY THAN OUR ABILITY TO RECEIVE THOSE FUNDS. (italics mine)

Earlier this week I noticed a large uptick in Google searches regarding early intervention that were landing on this blog so I started wondering what was going on. Turns out that there was a NYS Association of Counties meeting this week and the Department of Health gave a powerpoint presentation about the Governor's proposal. Copies of the powerpoint started to make their way around the State - and that got people doing some Internet searches for more information. Here is a link to the presentation for those who have not been able to see it yet.

The powerpoint doesn't offer information that is materially different than what is already listed in the proposed budget but it is in a more readable format.

The largest issues proposed include:
1. Providers will be approved through the Department of Health and won't have contracts with local municipalities.
2. There must be an arms length relationship between service coordinators, evaluators, and service providers.
3. Providers will be required to establish and maintain contracts or agreements with a sufficient number of insurers, including Medicaid and CHP.
4. Providers will have to use the State's Fiscal Agent to bill third party payors.
5. All of this will be achieved by a mandate on insurance companies requiring them to coordinate through the State Fiscal Agent to pay for EI services.

Details that are still a little unclear include how the rate will be negotiated. Currently, there is no alignment between EI rates paid by municipalities, rates paid by insurance companies, and the Medicaid rates. It is unclear whether or not the rates will change based on the information released so far. The current plan calls for providers to continue providing services whether or not they have been reimbursed - so there will need to be some clarity so providers understand the rule systems they are being asked to operate under for reimbursement.

It is likely that this will drive some providers out of the system and that will likely create delays in service provision. That means that private therapies, at least for families that have those resources, will likely replace the EI system as the de facto methodology for children receiving services. It is another form of indirect cost sharing, and is probably intentional.

Stay tuned for ongoing analysis.

Early intervention and preschool services to children who have disabilities will be scrutinized heavily in the upcoming year and many reforms are being discussed. This summary is a general outline of some of the salient drivers that are impacting reform efforts in New York State.

I strongly recommend starting your reading with the Reforming Mandates, Reducing Costs report that was written by the New York State Association of Counties. This report was submitted to the Medicaid Redesign Team last year to provide input about the unsustainable increasing costs of these programs.

Mandated Medicaid costs are crippling County budgets, and have been for many years. Most recently the State entered into a settlement agreement with the Federal Government often referred to as the State Plan Amendment. This settlement is the contract between New York State and Federal government whereby the State agrees to administer the Medicaid program in accordance with Federal law and policy. This agreement imposed backdated requirements that made it virtually impossible for Counties to receive payments for services that should have been reimbursable as they were compliant with rules in place at the time. This placed a very large strain on this particular component of Medicaid reimbursements to Counties.

Recently enacted property tax caps complicate the situation. You don't need to be an accountant or the County Comptroller to understand that rising costs, lack of reimbursements, and constricted income all spell a recipe for disaster. In short, Counties are being crippled by these programs.

County budgeting staff are at their wits end, and that is why you see proposals from Counties like removing them from the fiscal, contractual and programmatic responsibilities of the program, limiting eligibility to individuals that have greater delays in development, requiring some family financial participation based on income, increasing the County role in developing and writing Individual Education Plans, centralizing organization to the County as opposed to the district level, requiring parent participation for non-working parents, and eliminating contracting/fee for service arrangements because of the inherent conflict of interest with the current system. All of these and more recommendations were made to the Medicaid Redesign Team.

Some of these recommendations are more reasonable than others, but the point in reading this report is that it will help people understand the desperation of Counties.

Providers and parents may not understand these dynamics as well as they need too - I frequently hear calls to contact the NYS Department of Health, or to lobby the school districts, or to make noise in general to their legislators about how these services can not be touched. All of these call to action are potentially misguided. The ability to understand the problem starts at the level of the Counties and their Medicaid budgets and an analysis of the unsustainable growth of these programs and the inability to meet these costs within the current and expected fiscal environments.

You will not help this situation by yelling at your CPSE Chairperson. You have to start with your County legislators and understanding the broad dilemma that they are in.

Readers here are being informed that Governor Cuomo HEARS the Counties and UNDERSTANDS the dilemma. He released his Executive Budget yesterday that calls for some dramatic reform to how these systems are administrated. This WILL have a large impact on service eligibility and service provision - it WILL NOT just be a switch to billing a new entity.

Future posts here will cover the inability to NY State to effectively administrate EI billing, inability to recoup revenues, and inability to effective coordinate via the well-intentioned but very broken NYEIS system, the Counties' calls to the Governor to act on these problems, the rock and hard place of Counties with respect to the property tax cap, and what the Governor's proposals will mean for actual service provision.

This will also include a deep exploration of our own social and cultural values. The large question to answer is 'What is society's responsibilities for these programs.' It will be an interesting ride for the next couple of years as all this plays out.

Stay tuned for ongoing analysis.

I don't mince words, mostly because I lack time to do so and secondarily because I lack interest in political correctness. Let's talk straight about the Patient Protection and Affordable Care Act of 2010.

For some background and additional reading on the debacles that occur when government intrudes into health care decision making click on the 'health insurance' topics in this blog.

At the 2010 Legislative Conference for National Association of Counties, Nancy Pelosi made her now famous remarks

You've heard about the controversies within the bill, the process about the bill, one or the other. But I don't know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention -- it's about diet, not diabetes. It's going to be very, very exciting. But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.

Well we passed the bill and still nearly two years later we are waiting to find out what is in it.

The November 14th edition of OT Practice included an article by Jennifer Hitchon who is AOTA's regulatory counsel. Her article neatly summarizes the recently released Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost. The purpose of the IOM report was to survey stakeholders (aka insurance companies) about what products and services were deemed 'essential.' In other words - what is the bare minimum that these insurance companies are covering?

Now this is where I start to scratch my head a little - because the government determines that we need a new law to replace/supplement the 'evil profiteering health insurance companies' with government sponsored 'exchanges.' So, the government commissions the IOM to study the issue and the results of the study will go to the policy wonks who write the actual regulations that dictate what is in it. So then the IOM goes and asks the 'evil profiteering insurance companies' for their input so they can tell the policy wonks how to write better regulations than what is currently being done... oh... um.... hm.......

The IOM is non-governmental and advisory to the government and normally the IOM is a source to have faith in - but why survey/invite the fox to the hen house to determine what benefits should be considered 'essential?' I understand that the charge to the IOM was to come up with some package that was 'comparable' to what is being offered by most small business insurance plans - but how is the Affordable Care Act going to improve anything if all we do is base decisions on the cheapest available plans being offered by some small company that is already being squeezed by costs and is now choosing bargain basement health plans for its employees.

The lack of percipience into this issue is stunning, even for a government.

For fun I searched the IOM report for mentions of occupational therapy - you can view the mentions here. Most of the mentions relate to various inclusion/exclusion criteria of selected insurance plans.

The study includes some interesting statements that essential benefits should be medically oriented and not social or educational - which has rather large potential impact on all of pediatric occupational therapy practice. This same issue is being fought out state by state regarding insurance coverage for autism interventions and it will be interesting to see what the federal government does with the issue. I am curious how there will be reconciliation between exchange mandates and statutory requirements that have been written into state law about this coverage.

There are other notable exclusion points in the document related to some chronic conditions like intellectual disabilities and low vision. There is enough controversy for all. This doesn't mean that these will be automatically removed from 'essential' coverage determinations - but this all represents writing on the wall that people need to attend to.

Occupational therapists need to be watching this issue closely. Actually, the entire American public needs to watch this closely - but the complexities are beyond what many people have time or energy to follow, track, and decipher.

I encourage professional associations like AOTA to continue publishing about this issue as events unfold. However, we need straight analysis and not generic 'we will provide formal comments when the opportunity arises.' Practitioners and the public need to know the following:

1. The government may plan to model their exchange off of the cheapest possible plan that is offered by a small business.
2. Habilitation services could be on the proverbial chopping block, particularly if they can be labeled as 'educational' or 'social'
3. The plan may cover things like if your eyeballs fall out of your head, because that is a medical problem. However, if you need therapy or equipment to help you function you might be out of luck because that would be a personal problem and not a medical problem.

Many professional groups (MDs, etc.) are getting out IN FRONT of these issues by publishing position papers about what needs to be covered and why. The OT community needs to do more than simply respond during the comment period. AOTA needs to publish similar position papers about including a wide range of OT services in the act and increase visibility and lobbying about these issues. Practitioners have to start by educating themselves on what they are actually facing.

For the record, I would not characterize this as very exciting. I think it may be the largest boondoggle ever perpetrated on the American public.

Background reading:

2009

2010

Well this year the annual increase to our health insurance costs are only 19% but the plan has a higher out of pocket maximum and slightly fewer covered benefits so it isn't exactly the same plan. I thought I would be clever and call my Provider reps for the different plans and tell them that I would be shopping and purchasing based on information they could give me regarding 2012 fee schedules. Historically, even though the cost for these plans goes up exponentially the amount of increase that any provider might see is just a tiny fraction (and often even ZERO PERCENT) of that increase. Also, what happens each year is that the co-pays are increased so even though allowable fees might go up the costs are passed entirely to the consumer with higher deductibles and higher co-pays. In other words, the insurance company's objective is to put all of YOUR skin in the game and as little of their own as possible.

The mechanisms that allow this to happen are primarily attributed to a farce of a regulatory environment, absolute lack of serious competition in the marketplace, increasing federal and state mandates, and gross profiteering.

For the record, corrections and controls for these mechanisms were exactly what was LEFT OUT of the hilariously entitled Patient Protection and Affordable Care Act.

Anyway, I thought I would purchase a plan that at least dropped a few crumbs from the trough where the insurance company pigs feed. No such luck, because even though we are in the fourth quarter and they obviously have the actuarial data to set rates for insurance plans next year they all report that they don't have the data on what the fee schedules will be for providers. I individually asked the local insurance companies why they think I am stupid and why they are trying to make me believe that they set plan costs without already knowing reimbursements and cost outlays to providers. They were all really good at towing the company lines though - I have to give them credit for that. I am not sure if they really think they are fooling anyone and I also don't know if they sleep with a clear conscience at night but oh well.

I will continue to post these things here because I think it is important for people to know that when the insurance company sets a co-pay amount that is IN EXCESS of the allowed reimbursement to a provider - that means you are having your premium money STOLEN from you. Yes, this year we have plans that actually have $50 co-pays for specialist visits (which is what therapy is identified as) and the amount that they allow for reimbursement is just $42.50.

That means that you pay it all - and it also effectively means that your therapy is no longer a covered benefit - except that they are artificially price controlling your medical care to make sure that they will continue to make as much profit as possible.

The net result is that receiving many services like therapies will be restricted to larger hospitals and institutions that cover the cost by other revenue-enhanced activities like $1000 toothbrushes.

More next year... stay tuned...

Proposed changes to early intervention reimbursements have been temporarily shelved. Today Brad Hutton, Director of the NY State Early Intervention Program, sent out an email stating:

The Department has removed from this regulatory package the changes to the payment of home and community-based and facility-based visits. The Department remains committed to continued examination of the EIP reimbursement methodology and intends to have more discussion about this and other proposals with its Reimbursement Advisory Panel in the coming months.

I know that a lot of people are very happy about this, but it is important that we consider all of the events that led up to this recent decision.

As I have discussed here frequently in the past there is no question that there is need to revamp billing for this program to help support collection of payments from insurance plans. The problem is that we just witnessed and experienced an extraordinarily irresponsible and haphazard attempt to fix the problem. In fact, in attempting to 'fix' the problem, the direct actions of the Early Intervention Program administrators have reduced the numbers of providers who are still willing to work with the program and there have been program closings based in part on uncertainty that was created because of real and proposed cuts.

I know many therapists who left pediatric positions, I watched programs close, and I have listened to and participated in the worried conversations of therapists who were left wondering if they would even have a program to work in. I have directly observed the creation of waiting lists for services and watched families opt for private therapy because they didn't want to wait for the EIP or they were unhappy with the fact that experienced therapists were leaving the EIP. There has been significant damage already done - and NOTHING has been done to fix the underlying administrative problems with insurance billing. Instead, we have seen the NYS government legislate looser standards so that the EIP has a better opportunity to collect payments. In other words, the government has been unable to manage with efficient operations so they changed the billing rules for themselves.

And now are providers going to feel better about this email from Mr. Hutton? What is it that people are supposed to get from this? OH NEVER MIND! WE WERE JUST KIDDING ABOUT THOSE CHANGES. SORRY THAT KIDS DON'T HAVE ACCESS TO SERVICES LIKE THEY DID BEFORE. SORRY YOU QUIT YOUR JOBS. SORRY THAT YOU CLOSED YOUR AGENCY. SORRY THAT I BLEW THIS WHOLE THING UP.

How will this irresponsible email promote a sense of stability in the program? Based on past history, why would anyone trust the EIP? This will not cause agencies to have confidence to hire therapists and the waiting lists will likely continue.

I strongly encourage Governor Cuomo to appoint EIP administrators who have experience in the real world of EIP service provision. There are many private EIP agency directors who would have a better grip on the problems facing the program and how to introduce reform in a responsible manner. No one is served by whimsical flip-flopping, publication and retraction of proposed industry-changing regs, and an apparent inability to understand the impacts that these actions have on the program and most importantly on the families who depend on the program.

Also, our Governor needs to develop an improved system of regulatory reform review. NY State had this in concept with the Governor's Office of Regulatory Reform that was established under Pataki and subsequently dismantled under Patterson and Cuomo. Although not all aspects of this program were as successful as others, in concept it provided a mechanism of regulatory review that may have prevented the Early Intervention Program regulatory debacle. These governmental entities need to engage in real outreach to the constituents BEFORE regulations are proposed. That would go a long way to promoting a reality check when new regulations are considered.

Regulations have an impact on families and children who receive services from these programs, and they have an impact on the businesses in this state that are set up to deliver these services. Someone seems to have forgotten this fact.

We had a program that had funding challenges, and now we have a program that has funding challenges and a seriously demoralized workforce that has no sense of stability. It is shameful stewardship of this very important program, and New York citizens deserve much better.

Well I believe in equal opportunity blogging so when NYS does something correct with the early intervention program I have to herald the effort.



On August 17 Governor Cuomo signed a bill that facilitates payment of claims by health insurers to municipalities for early intervention services.



In a previous blog post I talked about the 85% denial rate that exists because the state government doesn't know how to collect from private insurance companies. This new law causes the IFSP to meet any precertification, preauthorization and medical necessity requirements imposed on benefits under any insurance policy.



There are additional new rules that prohibit insurers from denying claims based on the location where services are provided, the duration of the child's condition or that the child's condition is not likely to improve within a time specified in the policy, the absence of a referral by a primary care provider, or that the provider is a non-participating or non-network provider.



I would prefer that municipalities simply bill the same way that I do in my private practice. It would save a lot of time and hand-wringing about having to codify this into law and make excuses for government ineptitude.



Imagine if private practice billing could be made so easy with the stroke of a pen! Although this is ultimately good, it is also a lesson in how ridiculous it is that the government, being unable to play by the rules that everyone else on the planet are subject to, decides that the rules don't apply if they are playing. Hilarious.



Maybe I should try a letter like this:

Dear NY State:



The mean insurance company won't pay me because I don't like to follow the rules. I don't want to be a participating provider, I don't want to be subject to their timely filing requirements, and I don't want to answer to any of their demands. Therefore, please make them suspend all the rules for me - just like they did for you.

Do you think that would work?



Anyway, despite the hilarity of it all, it really is a good thing because the EIP will exist longer into the future if it is able to recoup money from insurance companies. This is NOT a new mandate - the insurance companies just got really good at denying EIP claims because no one in the EIP system knows about medical billing. Now the heavy handed government is going to make them pay whether they follow the rules of proper billing or not. I guess the Prince felt that he had to defend his State, blah blah blah. I know, I don't like the means either. Sigh.



Oddly, the United EI Providers Group made a little noise about this bill and lobbied people to try to stop it. As I mentioned before, I respect that they object to reforming EIP on the backs of providers but I think their analysis of this issue is as sharp as a marble. This law has nothing to do with direct access and it won't change all that much on the practice side of things and it is not a cleverly concealed stimulus program for primary care providers - so in total I just don't get the objections. Oh well.



So this was a good thing for the Early Intervention Program, even if it was a little Machiavellian.

The State Early Intervention Coordinating Council held a meeting on June 14 (yesterday) to accept or reject the new regulations regarding issues including the 15 minute increment billing and adjusted early intervention rate calculations.

I just finished speaking with Holly Kennedy from the EIP and she confirmed that the current rulemaking was rejected and that there will be a new rulemaking (look for the new Rules proposals in the Register around the end of June).

There will be another 45 day comment period (but no public hearings). Ms. Kennedy stated that some alternate proposals may appear in the rulemaking but she was not free to be specific about those at this time. I have some initial information about those proposals but won't publish my information until I can verify and source it.

Finally, I was told that any current service plans will continue in effect past any new rules - and will be revised on an individual basis during the regular review period.

When I get details about the new rulemaking I will post them here or if they are brief enough - on our Facebook page.

My apologies that this is more fact than analysis - but at this point I am figuring that anyone interested in this particular topic understands the issues. If there are specific questions I can address about any of this please email or comment.

Stay tuned.


UPDATE: 6/21/2011

I wanted to provide a link to the full meeting. It is rather lengthy, but for those who are inspired I recommend watching the section on revised rates, the section on proposed revisions (the 15 minute increment issue), and the public comment. You can access the video at http://www.totalwebcasting.com/view/?id=nysdoh

The EIP party line on proposed rate changes is that they 'can't comment' on them because they have not yet been proposed. The good news is that they scheduled some public forums to gather feedback but the bad news is that they scheduled the release of the regulation revisions AFTER the meetings.

The EIP reports that they expect to realize 6.2 million dollars in savings in FY 2012-2013 but that these savings will not represent significant changes in reimbursement. I believe this can be said with a straight face because they are operating under a general assumption that a 45 minute session length is standard. Of course it is not - as was expressed quite vociferously in the public comment period on the video.

I believe that it is dishonest to state that this level of funding cut won't be significant. I also believe that it is fundamentally dishonest to schedule public forums before the proposed changes are announced.

The jaw-dropping moment of the video happens around 182:53 when EIP Executive Director Brad Hutton stated, "I think its fair to say that actually these proposals came out of discussions at the RAP [Reimbursement Advisory Panel]... we felt like the genesis was the general public of external stakeholders." Someone needs to tell Mr. Hutton that with all the legitimate questions about following the NYS Open Meetings Law, the significant challenge with obtaining minutes of the RAP meetings, and believing that providers helped generate these back-door reimbursement cuts qualifies this statement as the Pinocchio Story of the Year.

Watching this video will help you understand that our government programs are inefficient, poorly managed, and unable to be financially maintained with all of the perpetual bureaucratic bloat and mandate.

Redux for practitioners: Continue to prepare for sea change in how you deliver your services.

Redux for families: Begin to plan for new ways to meet your children's needs.

Cost accounting is boring, I understand, but I hope providers and families read this so that they can empower themselves to push back against the systematic dismantling of the NYS Early Intervention program.

As previously blogged, NYS is engaging in a cost reporting process for the early intervention program. Cost accounting is a valid tool used by a business to establish actual cost for delivering goods or services.

Unfortunately, the NYS government is going about this process in a backwards direction. Generally, the results of cost accounting projects are used to inform stakeholders about costs so that appropriate reimbursement rates can be set. However, in NYS, the rates to providers have ALREADY been cut 15% in the last year and an additional functional cut of 33% is proposed to begin on July 1 by back-door manipulation of the billing and coding system.

Why then, is the NYS Department of Health engaging in an exercise of cost accounting when reimbursement cuts have already been made?

Many early intervention services in NYS are provided by independent contractors and small agency providers. Many of these people only dedicate a small portion of their productivity to the early intervention program. For example, an independent contractor may 'pick up' a couple EI cases to supplement their other employment. Alternately, a small agency may have individual staff see a couple EI cases as part of a much larger caseload that includes private work, contracted work, or preschool work.

NYS is asking providers to ATTEST to how much of their time and resources were assigned to the EI program in 2009. It is a burdensome exercise but it is possible to extrapolate how much revenue could have been achieved in a designated time frame in 2009. It is another matter altogether to make definitive statements on how much phone use went into the EI program in 2009, or how much equipment and supplies could be partitioned off to the EI program. This kind of information might be easy for an agency that exclusively or near exclusively provides EI services, but this is data that is not accessible on an ex post facto basis by most providers in NYS.

An easy solution to this would be to make it up, or designate use based on percentage of revenue generated - but this could be wildly inaccurate - and if the actual purpose is to gather valid data on how much it ACTUALLY cost to provide a service - you can't rely on proportional assignment of expense cost.

It is an additional matter altogether to ask someone to make an attestation that information is true and correct when it is impossible to know if the information is true and correct.

This matters because we don't really know what the state is wanting this information for - after all, the cuts to the program have already occurred!

Even more disturbing, the DOH is requiring detailed and proprietary business data including building/agency assets and staffing models which effectively equates to being required to divulge a business plan. It does not seem unreasonable to require providers who take taxpayer monies to conduct cost reporting on that aspect of work that is being subsidized by the government -but is it an over-reach to also require providers to provide in depth IRS-level accounting to a state agency that has no business having access to that data and when it is unclear what that information is being used for and why it is even being collected.

The slick answer from the state remains that they want to know how much it costs to provide EI services. The real solution is to do the following:

1. Develop a model that captures the full activities from referral to discharge, completing time and resource allocation studies on the entire EI process on a case basis. Gather enough data so that broad conclusions can be made about actual costs.

2. Study the cost differences associated with different models and organizational systems of care. It is possible that they could actually LEARN something from this level of analysis.

3. Develop the model and provide training so that time and energy can be recorded in REAL time, and not done ex post facto.

There is a deeply cynical side of my analysis that does not understand why this project is being completed. There are questions that inquiring minds want to know - and I have been asking them for over a month with absolutely no direct response to the questions:

1. Why is NYS Department of Health completing a cost accounting project "to inform stakeholders of actual costs to deliver services" when the stakeholders (the legislature via budget and the Governor via back door regulation change) have ALREADY CUT THE REIMBURSEMENT RATES?

2. Why was a model of ex post facto analysis chosen when the reality is that most agencies and providers did not collect the data in the form that is being required to provide?

3. Given that this is an ex post facto dive into data that may not even exist and in fact was never before required, why designate such a constricted time frame (one month) to comply with the reporting requirements?

4. Given that this is an ex post facto dive into data that may not even exist and in fact was never before required, why choose to do this in the month of April when many agencies and providers are FULLY engaged in fiscal end-year tasks, completing other tax and reporting requirements, and most pragmatically - when all the providers are eyeball-deep in meetings to help determine levels of service for CPSE and CSE children next year?

In sum, this process is ill-timed, intrusive, burdensome, seemingly irrelevant, and deeply flawed. This is your NYS Government hard at work to make these kinds of colossally irresponsible mandates.

We plan to soar over all of this, because we know that many people whose children need help will eventually develop workarounds and find ways to access services in other ways. When schools cut access to services or when NYS cuts EI reimbursement it does not change the fact that children still need services - and we have been a community provider meeting these needs outside of the care systems when needed and through the care systems when they are available.

My deep concern is for those children and families who don't have the resources to find those other ways.

Proposed rule changes for EI rates were published yesterday.

The main issue for practitioners to be aware of is that you will no longer bill for a 'basic visit' which in most cases consists of a 30 minute visit. Instead you will bill in 15 minute increments - but what is important to understand is that the rate you were previously paid will now apply to a base visit length of 45 minutes. That means that if you are continuing with your standard 30 minute visits that you will experience an additional 33% rate cut.

Whenever rule changes are proposed there needs to be impact statements - and NYS rulemakers have decided that cutting EI rates an additional 33% will result in increased job opportunities:

The proposed rule change for home and community services to full 15 minute billing increments may result in a minimal increase of employment opportunities as providers will have to align time spent delivering services with the time assumptions used to establish the rates. It may also provide an employment opportunity for providers of children who receive intensive services to provide a higher level of services through longer visits without incurring the cost of travel to a participant's home. Previously these intensive services may not have been cost effective or feasible to provide under the existing payment structure.

In other words they are stating that since providers will have to work 33% longer to make the same amount of money that this will cause agencies to hire more people to meet the same EI demand. Obviously the rulemakers have never directed an agency or owned a practice. I don't know how they can be so dishonest when they are writing these rules - it isn't even a matter of perspective - the impact statements are just dishonest.

What is more likely to happen is that agencies will not be able to hire therapists because no one will work for such a low rate and because there is no way for agencies to cover costs at current salary levels and at this low reimbursement. Current EI therapists and even entire agencies will bail out of the system and try to find work in other sectors - and indeed that will create job opportunities! No one will want to work in EI, so there sure will be a lot of EI jobs available.

On a serious note, this means that many children will not receive EI services - and that those families who have resources will access private resources/insurance to help themselves. Those families who do not have resources will be out of luck.

The bottom line here is that cost-sharing is realized because people who have resources will activate those resources and that saves the EI system and NY State money. However, the distribution of this cost-sharing is only an option for people who already have the resources - and if these rule writers knew anything about the demographics of the EI program they would understand that they just kicked a very needy population that doesn't have a lot of resources even further into the gutter.

I want to encourage people who are interested in updates on EI and other issues to follow our Facebook page at http://www.facebook.com/ABC.Therapeutics

I'll be posting brief updates there more often than I update the blog - which I generally reserve for longer rants or conversations. Blog traffic has spiked the last couple days so I know there are a lot of people out there looking for information.

The best information that I have available currently is that Senator Ranzenhofer's office confirmed to me that the EI rates have been cut 5%. In brief Facebook exchanges with NYSOTA they are also reporting the same information. A digital news service that covers NYC news is also reporting similar information. I spoke with people in the NYSDOH and EI programs specifically and they are keeping their lips sealed for now.

A 5% cut is better than the originally proposed 10% cut, but it will still create additional challenges for providers who are still accommodating to the 10% cut that occurred last year.

Right on the heels of all this news breaking I received an email from Public Consulting Group, Inc. (PCG) has been contracted by the NYS Department of Health to coordinate and implement a provider cost reporting system for the NYS Early Intervention Program. It involves filling out cost reporting forms and attending webinars on how to fill out their cost reporting forms - real exciting stuff that providers generally get excited over - right?

I called them up and asked what they want cost data on and they told me that it was to help provide data to stakeholders (I suppose that would include the legislature) about what the actual costs of providing EI services are. I fully understand the importance of cost reporting but to be quite frank it is rather ironic that they are gathering information on cost reporting AFTER cuts have already been made that are crippling ability to hire, train, and retain qualified professionals for the EI Program.

The consultant that I spoke to from this group was very pleasant but I gave her a 15 minute speech on the silliness of ex post facto cost reporting. I suggested that a better way to spend time would be to do a deep dive into the recently published early intervention report to the legislature. This report has shocking information about the absolute ineptitude of NYS in collecting money from third party insurers in their already-existing cost sharing allowances.

The report outlines an 85% denial rate that exists because our state government can't figure out how to cost share with commercial insurance - and the shocking 22% denial rate from our own Medicaid program! The primary reason for denials is not even because of exclusionary coverage rules or timely filing problems - but because providers do not 'participate' as credentialed professionals in the insurer's networks. That is a pretty lame reason to not get paid - and is so easily fixed by simply requiring that providers to EIP already be credentialed with Medicaid and whatever private/commercial entities serve their geographic area.

A tremendous amount of revenue is lost because of this - and rather than fix the problem I suppose it is faster to take an axe and lop off 5% of the reimbursement to providers. This has to be the laziest fix to a budget problem that I have ever seen before.

NY State doesn't know how to get paid for the services that are provided. Any private practitioner knows that you can't function if you don't get paid and now that lesson is about to be learned on a much larger scale across the state. You can't deficit fund forever.

One big part of the solution to all this is for everyone to learn how they can engage their own representatives and start talking about cost sharing through private insurance as a more reasonable model to support the costs of the program - unless you all know how to dodge the next clumsy swing of the budget cutting axe.

I guess that the state doesn't like Medicare rate cost reporting and the long-established formula that is already in place that has previously served as the basis of the EI rate. Maybe someone's friend owns this consulting group - I really don't know. I can't imagine why NOW is the time to do cost reporting - now that we are all about to experience another cut to reimbursement. Usually you might expect that they would make everyone do some little song and dance about cost reporting BEFORE they slash rates. That gives people the illusion that their input actually made a difference, a la the much exalted Medicaid Redesign Team. How funny is it that they slash rates first and then ask people to do cost reporting second?

Don't wait for NYS to figure it out - they are off on this new tangent that is best summed up with the phrase 'Ill-Timed.' Only government could be this dysfunctional.

If the number of hits to this blog regarding early intervention and the NYS budget are any indication - this is a MAJOR point of concern for therapists. Our traffic has been influenced heavily by this issue in the last month. Also, it is not just NY traffic - people around the country have been watching the proposed budget cuts to the NYS Early Intervention Program.

This week the Senate and the Assembly each put forward their own modifications to the budget and the budget reconciliation process begins. Click on the links to get to the respective budget proposals.

These documents don't always contain all the actual legislative language so it is sometimes difficult to precisely understand where specific budget lines are reflected. It appears that in the Senate version they are 'concerned' about the EI cuts and they are waiting on information about fund availability to see how they can 'minimize the impact of the Executive Proposal.' The Assembly version is more clear in that it 'rejects provisions to reduce the EI rate 10% and require providers to bill Medicaid directly.'

Insurance companies can rest easily, however, because in both the Senate and Assembly proposals they reject the requirements for expanding the mandate for commercial insurance companies to cover the Early Intervention Program. It is unfortunate that legislators didn't recommend a more reasonable cost-shifting plan that respected issues like network status of the provider, place of service, and prior authorization. Instead, they apparently over-reached by requiring a blanket mandate - and I can't really say I would support a blanket mandate either. It is reasonable for the insurance companies to have some typical process of utilization management but all or none thinking in this case will skew to the side of nothing happening. Big win for the insurance companies - big loss for the taxpayers. Blame the politicians for this one by being lazy and thinking a heavy governmental hand would be an effective strategy.

I am aware of several efforts to write in to legislators opposing the reimbursement changes. I am also aware of what appears to be a proto-union group that was able to get an Assembly bill introduced that would prohibit additional reductions to early intervention rates. I have corresponded with this group's leader and expressed some concerns about groups or professionals banding together (formally and informally) to set rates or to have the appearance of colluding about rates. I also have some personal philosophical concerns about the concept of collective bargaining against government entities. I was told that this was not a proto-union effort but this is one of those situations where if it looks like a duck and quacks like a duck it is probably not a rabbit.

Actually I admire this group's intent, and the group is comprised of parents and not only professionals, but I still think that this is like Little League playing at Yankee Stadium.

The lesson in all of this is that the way to effect change is to take the two following approaches:

1. Spend more money on lobbyists and become more active in the political process as it stands.

2. Instead of trying to be a break wall against the need for reform, try instead to ride the wave into another direction. In this case, it might mean helping families find the help they need from sources OUTSIDE of government mandated programs. That's a big mindset change against what many people perceive as an entitlement culture that exists in this state.

I have recently blogged about the State Plan Amendment that involved a $540 million settlement paid from NY State to the federal government because of Medicaid fraud. In the wake of the settlement, the Office of the Medicaid Inspector General has developed guidelines that municipalities are trying to understand, and in turn these guidelines are trying to be followed by local school districts and providers.

The current street level problem is that documentation requirements for services are being applied retroactively - and that causes even greater amounts of ineligible billing. In a mad rush to understand and comply with new requirements (I am hesitant to call them rules or guidelines) the locals are desperately looking for guidance on how they are supposed to provide services, document services, and bill for services.

Inspired people (like me) went to more than one training session and were shocked to find out that there were inconsistencies between the information that was presented at the trainings. The NYS Education department responded to the confusion by publishing two Q&A documents that attempt to clarify the training that every service provider in the state had to attend. The Q&As are the only official documents outside of the handouts provided at the mandated training.

Questions still persist because the requirements are confusing. Unfortunately, OMIG is no longer answering questions and is referring everything over to State Ed. I am not sure who is in charge of answering questions at State Ed but some rather odd information is being fed out of that department. One thorny issue had to do with what supporting documentation was needed for OTA supervision.

The State, as a de facto third party payor, has the right to require whatever they want to require - much as private insurance companies or worker's comp, or Medicare already does. The problem is that the information that is being disseminated is often incorrect and sometimes incomprehensible. Most recently, a municipality undergoing OMIG audit was asked to produce documentation of OTA supervision. The municipality responded by providing copies of co-signed notes, co-signed quarterlies, and other interim notes that were written by the OTR. There is no rule or regulation that dictates the EXACT nature of these notes - just that it is occurring on a regular basis to review treatment and foster professional development of the OTA. In my estimation the municipality provided appropriate documentation - but OMIG pulled out what appears to be some pages from an old NY City Medicaid billing manual that requires even more in depth documentation. The municipality forwarded this to the occupational therapist, who at that point felt under the gun for not providing the correct documentation. The municipality is not a regulator of any profession and is relying on State Ed or OMIG to provide correct information - so now the municipality thought that the OT wasn't doing the right thing!

Since when did an old NYC Medicaid billing manual supersede State Ed Law and previous documentation requirements of the Medicaid program?? The bizarre part of this all is that the presumed pages of the NYC Medicaid billing manual also have a requirement that OTs be registered by AOTA. I am not sure of the last time that AOTA registered anyone, since it is a voluntary membership organization. Back in the early 1990s AOTCB which was loosely connected to AOTA, provided certification for OTs and OTAs - but that function was taken over by the renamed NBCOT which spun off of the professional association and took full independence as a credentialing agency OVER 20 YEARS ago! Someone needs to update the NYC Medicaid billing manual, apparently.

Someone also has to stand up and ask why an old NYC Medicaid billing manual became the governing document for how to document services.

Also, these strange requirements out of an old NYC billing manual are being retroactively applied to providers across the state. People functioning in the corners of NY were not following the requirements of some arcane and outdated NYC billing manual - and the 'non-compliance' is being mathematically applied across the 'universe of claims.' So now old NYC billing requirements are being randomly applied in areas around the state that never before were exposed to these requirements. They aren't BAD requirements in themselves - but they were never before required.

The bottom line is that the municipalities will not be paid for many of the services that were provided because therapists in Niagara Falls did not think ahead and follow the old NYC Medicaid billing manual. That is insane. It is one thing to decline billing based on fraud - but it is quite another matter to apply some previously unknown standard to decline legitimate claims.

The point here is that people in OMIG and State Ed are just making this up as they go along. That places municipalities in the middle, and it places providers at the bottom of the pole trying to figure out what to do. I don't even know where it places the recipients of services - they are just lost in this whole mess.

I am sorry to report this - but it all gets worse. Paying back the money that was fraudulently billed is understandable - but now we are forfeiting money that should be legitimately paid on legitimate services. The Settlement Agreement signed by the Wizards of Albany effectively throw away your 8th amendment rights - so you are not secure against unreasonable fines and penalties. This is highly amusing to me - but how can a State toss out the 8th amendment rights of its populace? 'Excessive' fines and punishment takes on a very different meaning when it is applied to the State as opposed to an individual. Is anything 'excessive' when the State has unlimited revenue (your tax dollars)???

The dismantling of early intervention by making new Medicaid policy around the edges of the problem is a 'hiding in plain sight' issue, but to understand what is happening to early intervention you need to do a deep dive into power, control, and politics.

Counties are required to follow the requirements of OMIG if they want reimbursement, and they feed the requirements down to locals. The locals do not represent a politically connected constituency. Local providers are individual people who are often contractually related to municipalities. They are not represented by Unions, and their interests are only partially represented by their respective trade associations - none of which are particularly strong or powerful in Albany terms. To make matters worse, there are no formal lines of communication and coordination between the trade associations.

You can be absolutely certain that if a giant multi-million dollar settlement for Medicaid fraud came down on the heads of hospitals that HANYS would have found a way to see the 'draft' document and they would have filed an Article 78 proceeding or maybe even a lawsuit to make sure their interests were protected. There is no such political power among preschool or early intervention providers - and that made the constituency very easy pickings for the U.S. Department of Justice and the Wizards of Albany who were willing to have you all to 'take one for the team.' I am using polite terminology.

This was all predicted nearly six years ago. Still, let me assign blame all around because if we understand our role in the problem then maybe we can adjust our priorities and make sure we don't end up with this happening again.

1. I blame myself, because despite my blogging and ranting about it I was largely ineffective in communicating the issue to relevant stakeholders who might have helped to engage the problem.

2. I blame all the people who label this post as 'boring' and write me emails wondering why I don't write more about treatment ideas. This is a population of therapists that is too large and they need to understand that lack of political engagement is jeopardizing care to a very vulnerable population. Also, jobs are now at stake - that may wake some people up. I especially worry about the OTA and PTA population, because based on new burdensome requirements there is significantly less reason to hire or employ these professionals.

3. I blame educational programs that have ultimately failed to educate therapists on the importance of policy on practice.

4. I blame all the trade associations who needed to see this as a very top priority and neglected to give this issue the attention/resources it was due.

5. I blame municipalities for not fighting back. I do not know if a municipality has standing to contest an agreement made by the State with the US DOJ, but on principle alone they should have been less passive.

6. I blame politicians and lawyers who brokered all this and actually understand this whole issue really well. They do not have the courage to address problems directly so instead they take aim at a disenfranchised group of service providers who have no political clout to do anything about it.

All of this will save NY State untold millions of dollars. This is something that is needed - but it will all happen on the back of our educational system for disabled children. There is no question that we needed reform but of all the places to squeeze money out of the system is this really the place to start?

Here is information from Governor Cuomo's 2011-2012 proposed budget. You can find supporting documents and presentation at http://publications.budget.state.ny.us/eBudget1112/fy1112littlebook/index.html

I have BOLDED the proposed budget information and italicized my own comments:

Several changes are suggested for the early intervention program that provides services to children aged 0-3 who have qualifying conditions or developmental delays.

• Recalibrate Early Intervention Rates. To make the cost of Early Intervention more affordable, a variety of changes will be made to payments for Early Intervention providers. These include the following:

- Rate Reductions of 10 percent for Early Intervention. A 10 percent across the board rate reduction will be applied to all Early Intervention service rates. (2011-12 Value: $11.1 million; 2012-13 Value: $24.3 million)

n.b. a 10% rate cut was enacted LAST YEAR. It will be interesting to see if the lower reimbursement rate drives providers out of the program. That may be the actual intent. Fewer providers means fewer reimbursements.

- Restructure Early Intervention Billing Practices. Providers of Early Intervention that receive more than $500,000 in Medicaid revenue annually will be required to directly seek reimbursement from Medicaid and private insurance prior to seeking payment from municipalities for these services. (2011-12 Value: $0.5 million; 2012-13 Value: $1.9 million)

This is a cost shifting technique that has significant implications for large providers. Many are not equipped to handle Medicaid or private insurance billing and have no experience in this area. There will be a steep learning curve for agencies who will have to learn how to navigate these systems. Furthermore, there are delays associated with getting reimbursements from these systems and that may have a significant impact on the cash flow and financial health of the larger agencies.

- Maximize Commercial Insurance Reimbursement for Early Intervention. Insurance companies will be required to pay legitimate claims for Early Intervention Services. Currently, only $13 million, or 2 percent of total gross program costs are paid by private insurance companies, although over 40 percent of children enrolled in the program are covered by private insurance. (2011-12 Value: $0 million; 2012-13 Value: $24.6 million)

This is another cost shifting technique, which has merit but there are significant problems in implementing this. Some municipalities are encouraging providers to become 'approved providers' with local insurance companies so as to allow for recouping costs from the private insurance - but the municipalities have absolutely no experience in knowing how to negotiate fair and reasonable rates with the insurance companies. In one County where we work we were asked to become an EI provider with an insurance company and the proposed reimbusement rate sheet was less than half of the prevailing rate that the same insurance company pays me to see people privately in my office. I refused to sign the contract because of my concern that a day would come where I would have to bill the insurer directly for EI services (as stated above!) and I would be 'locked in' to a substandard reimbursement structure. After refusing to sign a contract for well over a year and after many attempts at educating the municipality on the prevailing wage for therapy sessions, the insurance company finally adjusted the reimbursement for EI to appropriate community standards. The problem here is that the municipality does not know anything about prevailing reimbursement standards and the insurance company was quite adroitly trying to pull a fast one on the municipality. I am still waiting for a thank you letter from that municipality - I believe that I saved them several hundred thousand dollars annually by educating them on prevailing reimbursement rates and by holding out on the contract until the insurance company adjusted the rates accordingly.

- Recover Early Intervention Overpayment for Medicaid Transportation. Achieve savings due to recoupment of $6.2 million in the State’s overpayment for Medicaid transportation costs. This proposal will recover the overpayment from counties. (2011-12 Value: $6.2 million; 2012-13 Value: $0 million)

- Modify Early Intervention Service Coordination Rates to Use Capitation. In order to achieve programmatic efficiencies, capitated rates will replace the current methodology of billing in 15 minute increments for service coordination. Service coordination will be paid at a single rate per event or per month regardless of the amount of time spent managing the child’s case. (2011-12 Value: $0.3 million; 2012- 13 Value: $0.9 million)

- Bill Early Intervention Services in 15-Minute Increments. Fifteen minute increment rates will replace variable unit increment rates (basic and extended). Currently, basic visits are for up to 59 minutes of contact time with a child and an extended visit is for 60 minutes or more. (2011-12 Value: $1.6 million; 2012-13 Value: $6.2 million)

This has already been implemented in 2010-2011. This allows them to be on an encounter-based billing methodology that is consistent with third party payers, but there is a rather steep learning curve for all of the providers - most of which are not accustomed to operating in a medical billing context. They have not yet started reimbursing providers on this encounter based system - perhaps that is next?

- Revise Early Intervention Rates to Update Wage Equalization and Transportation Factors. Rates for home and community-based visits will be revised to reflect updated wage equalization factors that account for salary differences across the State. In addition, other changes to the prices will be made to adjust travel time assumptions which are assumed in the rates. (2011-12 Value: $0.9 million; 2012-13 Value: $1.4 million)

It will be interesting to see what this actually means. You can be sure that upstate people will cry foul if their rates are cut more than downstate - based on cost of living factors. The rates are already geographically adjusted so new adjustment formulas may be suggested.

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The sounds that you are hearing are the beginning cries of special interest groups who will do anything to avoid these cuts. The need to cut is real - and some of these suggestions are helpful. I am disappointed that more was not suggested about implementing better utilization management and setting entrance and exit criteria for the program. There is cost savings that will be realized by across the board slashing - but this is not a particularly thoughtful way to enact reforms. You can be more precise with a scalpel than you can with a hatchet, but perhaps the fiscal crisis is so severe that the Governor does not care much about making nuanced decisions and adjustments.

I was impressed with the good attendance at the public hearing and the attendees represented a Who's Who of Health Care and Human Service Providers in WNY. There were CEOs from most major hospitals, directors of community service programs, community activists, and consumers. Their interests ranged from emergency room care, medicaid transportation, primary care providers, hospital and nursing home care, residential programs for people who have developmental disabilities, mental health agencies, substance abuse agencies, and so many more.

I was deeply saddened that I was the only person there who talked about Medicaid in education and early intervention.

These comments were hashed together from old blog posts and other rantings:

My name is Christopher Alterio and I am a pediatric occupational therapist. Thank you for the opportunity to provide information from a street-level provider's perspective on the Medicaid program and funding for early intervention, preschool, and school special education services.

No one questions the need to reform Medicaid, but I am calling for a scientific and evidence based process to be used when reforms are being implemented.

Reform is hard but reform can be good when it is done correctly. The problem with recent efforts of cost control are that reforms are being driven by political expediency and to satisfy legal settlements. Recent cost controls have included a 10% pay cut to early intervention providers, removing minimum service requirements for some therapies, and allowing for higher student to teacher ratios in special education classes.

The problem with all these changes is that there is no evidence that indicates this is the best way to reform or modify the system. This is pure knee-jerk reaction to a budget shortfall and has nothing to do with best practices. So, as we all continue to pay for waste, fraud, and abuse throughout the system - our elected officials are making cuts to budget lines without any apparent regard for evidence. Also, these reforms are being made within the regulatory and rule making process that has some procedural safeguards for public participation but it does not seem that input into that process seems to make any difference.

Our special education system and its funding mechanism is broken and now we have a real chance to improve.

I believe that this particular situation provides an opportunity for districts to begin looking at their models of service provision and see how to provide services more efficiently. That includes setting appropriate entrance and exit criteria for related services, adopting evidence-based or RTI-type models for educational intervention, and improving team building to ensure that services are reinforced in a transdisciplinary way throughout the curriculum. All of these strategies would help improve the efficiency and also the quality of special education services. They would also by design promote cost savings and prevent Medicaid waste.

Professionals also have new opportunities to improve focus on school-home carryover. Parent involvement is critical for positive educational outcomes and may be the largest underutilized resource in the special education equation.

I am not speaking code for decreasing related services and abdicating responsibility to parents. I am talking about an open dialogue about educational best practices and establishing responsible and defensible criteria points for intervention. We have had too many years of poor oversight, lack of accountability, and variable interpretation of special education regulations. I am a practitioner who provides services across dozens of school districts and I can report that there is almost no consistency between districts in how the special education system is administered. This is shocking, particularly in consideration of the tremendous legal process and regulatory requirement that is already present in the system.

In all fairness, there is indeed a price for the fraud and abuse that has existed in this system for many years - but you do not solve the problem with fraud and abuse by failing to address the real problems. New York State has a long history of policy making on the periphery - we decrease service utilization and try to save money by layering complex rule and regulatory changes for Medicaid reimbursement - when what we need to do is establish criteria for the service utilization itself and standardize administration of the program across the State.

We cannot continue to make policy on the periphery of this problem by layering bureaucratic solutions for reimbursement at the feet of school districts or providers. When you present your report to Governor Cuomo, please include reforms that are targeted at the heart of the problem. That means that we need standard procedures, standard entrance and exit criteria, and evidence-based interventions.

Thank you very much for your consideration and for the opportunity to present this information.

If you were unable to attend the meeting you can provide online comment at http://www.health.ny.gov/health_care/medicaid/redesign/

I think it is important for this team to hear from more people about Medicaid reimbursement for services to children. They got an earful from every other constituency - and early intervention and education people need to show up for this conversation.

The NYS Early Intervention Program recently issues some FAQs on some regulation revisions that happened in June 2010. These changes are insidious and fly beneath the radar of most people because they constitute rules and regulations that can be administratively altered without a full deliberative process that is associated with actual changes to law/statute.

I figured I would post this today because it is a new year and I think that everyone needs to keep their ears to the ground for changes in rules and regulations that will have a significant impact on the way that health care is delivered on local, state, and federal levels.

This particular gem places additional stress on an already over-burdened New York State Budget. The regulation states that social security numbers and citizenship are required for participation in the early intervention program, BUT NOT REALLY.

June 2, 2010 - Webinar 1 - Overview of Revisions to the EI Regulations
Frequently Asked Questions

1. Question:
Are parent and child social security number required? What if a parent refuses to provide or does not have a social security number?

Answer:
The social security number of the parent and the child are required. However, not having a social security number does not preclude a child from participating in the EIP. If a parent refuses to provide their social security number, the refusal should be documented in the child’s record by the Early Intervention Official or designee (EIO/D), but the program continues to be available to the family. There is no citizenship requirement for eligibility in the EIP. The Department has developed a standard form that municipalities may use for this documentation.

The purpose of requiring SS# and citizenship is so that there can be some mechanism for the state to obtain reimbursement for the services provided (private insurance or perhaps federal Medicaid).

Rather than make effort to increase reimbursement for these services, the state - via their Enforcement Arm (OMIG) - places providers in the crosshairs with a tangled array of ever-evolving documentation and billing requirements that make payment to providers less likely.

Do the math: Allow anyone into the program, whether they can pay or not. Then pinch the providers and find as many reasons as possible not to reimburse for the care that you are mandating. Does anyone really think this will lead to a sustainable service?

The large question is: What is the end game? I predict a socialized system or a mandated unionization of the EIP workforce that will functionally accomplish the same end...

...unless the citizenry starts understanding the insidious world of administrative rule making manipulation in health care that we are now entering.