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Thursday, December 7, 2023
Courthouse News Service
Thursday, December 7, 2023 | Back issues
Courthouse News Service Courthouse News Service

Medicaid Conditions Hit Mental Health Centers

WASHINGTON (CN) - The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) have, for the first time, adopted Conditions of Participation for mental health centers, the agency has announced.

Previously, the lack of oversight of Medicare-certified Community Mental Health Centers (CMHCs) had led to abuses, including questionable billing practices, CMS said.

The new regulations aim to address the abuses, and to ensure quality and safety for care provided by the centers, "regardless of payment source."

"The regulations focus on a short-term, person-centered, outcome-oriented process that promotes quality care," the CMS said. The requirements encompass such things as personnel qualifications, client rights, admissions, patient evaluations, treatment plans and administration of services.

The CMHCs are expected to use in-house quality management systems to self-monitor performance and compliance, the CMS noted.

"Bridging these CMHC requirements are quality assessment and performance improvement program requirements that build on a provider's own quality management system to improve client care performance. We expect CMHCs to furnish health care that meets the essential health and quality standards that are established by this rule," CMS said in its action.

Many facilities, however, have not met even the basic standards.

Under the Medicare program, the CMHCs are recognized as Medicare providers only for partial hospitalization services. Under the Omnibus Budget Reconciliation Act, they must also meet licensing or certification requirements for the state in which they operate.

"However, CMS has learned that most states either do not have a certification or licensure program for these types of facilities, or have regulatory requirements that apply only to CMHCs that receive Medicaid or other direct state funding," the agency said.

That means some facilities have been left unchecked and unregulated.

Additionally, when the partial hospitalization program benefit was first enacted, CMHCs were self-certified.

This system has not worked well.

"CMS has received complaints regarding some CMHCs, such as their ceasing to provide services once the CMHS has been certified, physically mistreating clients, and providing fragmented care. As there are no [Conditions of Participation] in place for CMHCs, many participating CMHCs have never had an onsite survey visit by CMS after their initial certification," according to the action.

As a result, CMS previously did not have much latitude in its response to complaints.

"There are currently only certain circumstances in which CMS can terminate a CMHC from Medicare participation based on the result of a complaint investigation. Without such health and safety standards in place, CMS's oversight of CMHCs is severely limited," the agency noted.

The agency suggested in its action that the lack of oversight has also resulted in questionable billing practices. A 2012 study conducted by the Department of Health and Human Services, Office of Inspector General shows that fraud has occurred.

During 2010, 206 community mental health centers received an estimated $218.6 million for providing partial hospitalization program services to approximately 25,000 Medicare beneficiaries with mental disorders, according to the OIG.

"In 2010, approximately half of CMHCs met or exceeded thresholds that indicated unusually high billing for at least one of nine questionable billing characteristics. Approximately one-third of these CMHCs had at least two of the characteristics," the OIG said in a report.

The report described past OIG studies that have found vulnerabilities in Medicare payments. In 2011, four CMHC owners and managers in Miami-Dade County, Florida, were convicted of fraudulently billing Medicare approximately $200 million for medically unnecessary partial hospitalization program services."

The regulations went into effect Oct.29.

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