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“I FEEL LIKE IT WOULD BE A DETRIMENT TO THE COMMUNITY TO LET OIG WIN, TO CLOSE MY PRACTICE TO MEDICAID PATIENTS. I HAVE A REAL CONNECTION TO THE COMMUNITY, WHICH HAS BEEN SO SUPPORTIVE.”


BAD FOR BUSINESS


When he found out he was the target of an OIG investigation and potentially owed the state $22 million in fines and penal- ties, Dr. Wood contacted his attorney, Mark Chouteau. Shortly thereafter, he received another letter notifying him OIG would withhold all of Carousel Pediatrics’ Medicaid payments during the investigation. Carousel’s high Medicaid patient load may be what attract- ed OIG’s attention in the first place, Dr. Wood says. “The clinics serve as an innovative medical home for a large number of Austin-area Medicaid children. The fact that we bill Medicaid at such a high rate may be what caught us in OIG’s radar,” Dr. Wood said. Dr. Wood had an independent certified coder review OIG’s findings and compare them with the clinics’ records and docu- mentation.


“The outside coding expert disagreed with or rendered ir-


relevant about 85 percent of OIG’s findings, but did find some coding mistakes on the part of Carousel Pediatrics. We ac- knowledge some mistakes and are willing to remedy them, but they account for fewer than 3 percent of the cases reviewed,” he said.


One of the offices mistakenly coded throat cultures as blood


cultures, for instance. “It was an accidental overcharge on our part,” Dr. Wood said. Clinic officials periodically audit coding, Dr. Wood says, but some mistakes must have gone undetected. TMA can help physician practices avoid coding mistakes. TMA Practice Consulting offers coding and documentation services that help practices identify any areas of concern and make adjustments. (See “Coding Anxiety? TMA Can Help,” op- posite page.)


Another mistake involves Carousel billing Medicaid for af-


ter-hours patient care. Dr. Wood says the clinics are open until 9 pm during the week and are open a few hours on weekends. The clinics’ contracts with their Medicaid managed care plans and HMOs authorize them to bill for after-hours services. But


20 TEXAS MEDICINE December 2012


the clinics’ contract with Texas Medicaid & Healthcare Part- nership (TMHP), which administers the traditional Medicaid program, didn’t authorize payment for after-hours care. “TMHP knew we were charging for after-hours services, but


no one told us not to or questioned the billing,” Dr. Wood said. “By staying open later and on weekends, Carousel Pediatrics saves the state money by keeping children out of the emer- gency room. We also improve access by having more flexible operating hours that make it possible for working parents to bring in their children.” Mr. Chouteau and Dr. Wood met informally with OIG ear-


lier this year to appeal the payment hold. Dr. Wood gave in- vestigators copies of his contracts with Medicaid managed care plans and HMOs, the independent coder’s analysis of the records, and a letter from Superior Health Plan praising Dr. Wood and the care Medicaid children receive at his clinics. Carousel contracts with Superior, a Medicaid managed care organization that came to the clinics’ defense upon learning of the OIG payment hold. “That organization was able to convince OIG there would


be a real access-to-care problem if Carousel Pediatrics couldn’t provide services to tens of thousands of area Medicaid chil- dren,” Mr. Chouteau said.


OIG lifted the payment hold for the Medicaid managed care


organizations and HMOs Carousel contracts with, but not for payments from the traditional state Medicaid program admin- istered by TMHP. Dr. Wood estimates the clinics lose about $40,000 per month due to the payment hold. As a result, Dr. Wood had to reduce staff by about 20 per- cent. He also closed one Austin clinic over the summer but re- opened for business in the fall. At Superior’s urging, he opened three clinics in the Rio Grande Valley earlier this year but had to close them all one month later because of the investigation. Following the meeting to appeal the payment hold, Mr.


Chouteau and Dr. Wood compiled 800 pages of documenta- tion supporting the clinics’ billing claims and submitted the information to OIG in May. Mr. Chouteau says once OIG has


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