Members Of NM Delegation Introduce Bill To Prevent Suspension Of Medicaid Services Without Thorough Investigation

WASHINGTON, D.C. - U.S. Sens. Tom Udall and Martin Heinrich, and U.S. Reps. Ben Ray Luján and Michelle Lujan Grisham introduced the Medicaid Program Integrity Enhancement Act of 2016. The bill protects Medicaid patients by establishing clear guidelines that ensure that state agencies investigating allegations of fraud do so in a manner that both protects health care consumers and affords due process of law to the health care provider.

The introduction of the bill comes after the New Mexico Human Services Department (HSD) unnecessarily suspended Medicaid payments to 15 behavioral health providers claiming allegations of fraud nearly three years ago. This decision upended New Mexico's behavioral health system overnight, disrupting care to some of our state's most vulnerable residents. Since then, and following an investigation by New Mexico Attorney General Hector Balderas, 13 providers accused of fraud have been cleared. Additionally, the First Judicial Court of New Mexico has ruled that HSD violated the due process rights of several of the behavioral health providers when it withheld payments indefinitely without an opportunity to appeal the state's decision. 

"Behavioral health services like substance abuse treatment and mental health care are critical for many of New Mexico's most vulnerable," said Sen. Udall. "The state's reckless decision to suspend Medicaid payments without notice forced several trusted providers to shut their doors, leaving patients at risk without the services they rely on. Due process of law is designed to prevent unwarranted actions like this, and we need to make sure vulnerable New Mexicans and health care providers have strong safeguards in place to ensure this crisis never happens again. Our bill puts a simple principle in place: patients over politics."

"Investigating fraud and providing access to quality health care to patients are not incompatible. The bill will ensure that both goals can be achieved simultaneously," said Sen. Heinrich.  "New Mexico's behavioral  health system was turned upside down overnight when the state unilaterally suspended Medicaid payments for vital services. It's clear that this was a manufactured crisis that dangerously left patients without the care they deserved and had come to rely on. Our bill would ensure this never happens again."

"When the State of New Mexico decided to unnecessarily suspend payments to 15 behavioral health providers, the system was thrown into chaos," said Rep. Luján.  Even though one provider after the next has been exonerated of the charges leveled against them by the State, the damage has been done - vulnerable New Mexicans have experienced disruptions in services and providers have been forced to close their doors.  The legislation we have introduced will guarantee the due process that none of these organizations were provided and ensure there is a process in place that provides additional review while protecting access to vital services and continuity of care.  New Mexico's behavioral health system has been needlessly broken and this bill will help prevent anything like this from happening again."

"As we continue fighting for justice for New Mexico providers and patients, we must also establish protections that prevent such a reckless decision in the future," said Rep. Lujan Grisham. "This legislation would ensure that this never happens again."

The Medicaid Due Process Integrity Act  has the endorsement of the National Council for Behavioral Health. "Fraud and abuse in Medicaid must be taken very seriously. Yet, as the cases in New Mexico show, upstanding providers must be protected from unsubstantiated allegations," said Linda Rosenberg, President and CEO of the National Council for Behavioral Health. "Just as in any part of our legal system, individuals and organizations deserve to know the allegations against them and to have those allegations investigated and resolved in a speedy manner so that we can prevent future crises like that seen in New Mexico. In the New Mexico case, patients' access to care evaporated practically overnight. State Medicaid agencies must carefully consider how their decisions affect patients who rely on these services every day. We thank Senator Heinrich and Representative Luján for introducing this important legislation, and Senator Udall and Representative Lujan Grisham for joining as original cosponsors."

The Medicaid Due Process Integrity Act would:

1. Prevent unnecessary payment suspensions by requiring a Medicaid agency to consult with a state attorney general on the credibility of allegations prior to suspending payments.
2. Protect beneficiary access to care by requiring a state to consider the impact a payment suspension may have on beneficiary access to care-prior to withholding payments.
3. Guarantee due process of law by requiring states to cease payment suspensions where an investigation has ended after 18 months.
4. Require states to create an appeal process for providers to challenge charges against them.

Last month Udall, Heinrich, Luján, and Lujan Grisham sent a letter to U.S. Health and Human Services Secretary Sylvia Burwell calling for a thorough investigation of the findings in the New Mexico Attorney General's report that cleared 10 providers of fraud, bringing the total to 13 providers that have been exonerated.