Provider’s Complaint Prompts Call for Audit of Medi-Cal

SACRAMENTO, Calif.–A Joint Legislative Audit Committee has
agreed to an audit of Medi-Cal after a home medical equipment
provider challenged the California Medicaid program over fee
schedules that pit providers against a little-known law.

The committee of state Assembly and Senate members convened on
Aug. 29 to consider the issue, which was brought before the panel
by state Assemblyman Rick Keene of Chico.

“They agreed unanimously that they needed to make a
determination on which law prevailed,” said Tom Lambert, president
of Maximum Comfort in Redding. Lambert enlisted Keene’s help in
taking the case to the JLAC after Medi-Cal auditors told him and
other California HME providers that they were violating state law
by submitting power wheelchair claims above state law limits–even
though the claims adhered to Medi-Cal fee schedules and were
pre-approved.

The claims, according to the auditors, exceeded the limits
established under Title 22. Passed in 2003 with the intent of
fighting HME fraud, the law essentially places a ceiling on what
providers can bill Medi-Cal. However, Medi-Cal fee schedules
generally exceed that ceiling, which tops off at 100 percent above
invoice. (See
HomeCare Monday, Aug. 27.)

“We’re following the rules given to us by the Department of
Health Services but we’re made out to be the bad guys,” Lambert
said.

Lambert said he was heartened by the committee’s call for an
audit by the Bureau of State Audits. The audit should begin in
October, he was told, and take about 60 days.

Bob Achermann, director of the California Association of Medical
Equipment Product Suppliers, also applauded the committee’s ruling
but is cautious about its impact.

“It remains to be seen as to how all this comes out,” he said,
noting that the Bureau of State Audits can only make
recommendations and observations; it cannot change laws. “They are
going to look at [the issue]. What we don’t know is what they are
going to find or what they are going to conclude.”

Another unknown is how Medi-Cal will respond to the bureau’s
findings, he said.

Achermann also warned that the Medi-Cal audit wouldn’t
necessarily end the audits of California HME providers that are
already under way or on the audit dockets. Through those audits, at
least a dozen HME providers, including Lambert, have been hit with
sizeable repayment notices ranging from $50,000 to $500,000.

The Medi-Cal audit, Achermann said, simply “lays the groundwork
for legislation.”

Keene’s press secretary, Evan Oneto, said the next step hinges
on the audit results. “Their findings will have a great bearing on
what we decide to do with it,” he said. “If they find that these
two standards are different, then we need to fix that.”

That was encouraging to Lambert. He said he expected that
Medi-Cal would eventually release the $165,000 it has offset from
him as part of the $469,000 it demanded in repayment, and he
anticipates the same for other providers in similar situations.

Lambert credited Keene with the JLAC victory. “He didn’t just
save me, he saved all the dealers in California who do Medi-Cal,”
he said.