STATE OF NORTH CAROLINA IN THE OFFICE OF
ADMINISTRATIVE HEARINGS
COUNTY OF MECKLENBURG 05 DHR 1165
SETAPART, MARLONNA THOMAS )
Petitioner, )
)
v. ) DECISION
)
N. C. DEPARTMENT OF HEALTH )
and HUMAN SERVICES, DIVISION )
OF PUBLIC HEALTH )
Respondents. )
This matter came on for hearing before the undersigned administrative law judge on January 30, 2006, in Monroe, North Carolina. Brandon M. Lofton of Ferguson, Stein, Chambers, Gresham & Sumter, P.A., represented Petitioner. Mabel Y. Bullock, Special Deputy Attorney General, represented Respondent.
ISSUE
The issue is whether Respondent properly denied Petitioner’s re-certification application for HIV Case Management Services (HIV CMS).
FINDINGS OF FACT
1. The AIDS Care Unit, Division of Public Health, North Carolina Department of Health and Human Services, has authority to certify, re-certify, deny re-certification or decertify agencies or organizations that are interested in becoming providers of HIV case management services to Medicaid-eligible clients. This is not a direct service program. The case manager does not get reimbursed for direct services.
2. HIV case management is a client-focused strategy for coordinating care. It involves assessing a client’s need for specific health, psychological, and social services and facilitating access to the specific services that will address those needs.
3. Entities wanting to be providers of case management services must file an application for certification with the AIDS Care Unit. The application will be used to determine whether the agency or entity meets the criteria for providing those services. If an entity is certified, the Division of Medical Assistance will be notified so that the process for enrollment as a Medicaid provider may be initiated.
4. SETAPART, Petitioner, was first certified in 2002 as an HIV case management agency.
5. A Quality Assurance site visit was made to SETAPART on March 22, 2005. Beth Karr (Public Health Nurse Consultant), Bob Winstead (Public Health Program Consultant), Trisha Hailperin (Public Health Program Consultant) and Victoria Landes (CAP/AIDS & HIV Case Manager Consultant), conducted the Quality Assurance site visit to review the agency’s HIV Case Management and CAP/AIDS programs. On the day of the visit, SETAPART’s staff had difficulty locating case management files. Once the requested records were produced, the files reviewed were incomplete. It is found as a fact that the above site visit was made to SETAPART on March 22, 2005. Petitioner alleges that there were no other technical assistants site visits made prior to March 22, 2005. Respondent alleges that there were other technical assistants site visits made prior to March 22, 2005. There is inadequate evidence in this record to find as a fact that Respondent made any particular number of other technical assistants visits prior to March 22, 2005.
6. It was concluded, by Respondent, after the Quality Assurance site visit had been conducted, that SETAPART was in non-compliance with HIV Case Management Program regulation, 10 NCAC 22O.0124. Also the agency inappropriately billed Medicaid for direct service delivery such as shopping for clients and transporting clients. In one chart, none of the eight core components of HIV Case Management (Intake, assessment, Care Plan, Resource Development, Service Coordination, Monitoring, Reassessment, and Discharge) had been completed and the agency inappropriately billed Medicaid for providing case management services. Based on the findings of the Quality Assurance site visit, SETAPART was referred to Program Integrity at the Division of Medical Assistance regarding case management billing submitted to Medicaid for the period January 2002 through December 2004. Respondent’s Exhibit 4 contains a summary of findings of the Quality Assurance visit.
7. The staff of SETAPART met with the consultants at the end of the Quality Assurance visit and were informed of the problems that were found. SETAPART staff informed Respondent’s consultants that SETAPART had experienced a client crisis during Respondent’s visit which complicated accurate file retrieval.
8. A progress note provides documentation for a billable contact. It is not the progress note that is billable, but the activity or service. In order to be Medicaid billable, a provider must have written and signed documentation that the service was done.
9. N.C.G.S. § 108A-25(b) provides that “The program of medical assistance is established as a program of public assistance and shall be administered by the county departments of social services under rules adopted by the Department of Health and Human Services.” (Respondent’s Exhibit 7)
10. 10 NCAC 26B .0124 provides rules for case management services. (Respondent’s Exhibit 7)
11. The Case Management Provider Manual (Respondent’s Exhibit 12) provides details about the case management program.
12. During the process for re-certification, Respondent found that SETAPART had failed to properly document and sign progress notes and also inappropriately billed Medicaid for case management services.
CONCLUSIONS OF LAW
1. The parties properly are before the Office of Administrative Hearings and each stipulated on record that notice of hearing was proper.
2. As a certified case management service provider, SETAPART, Petitioner, is bound by the statutes and rules governing the program.
3. A preponderance of the evidence showed that during the process for re-certification, Respondent found that Petitioner SETAPART had not complied with the eight core components of HIV Case Management, 10A NCAC 22O.0124.
4. Based upon the preponderance of the evidence, Respondent did not act in an arbitrary or capricious manner in administering the rules and laws applicable to the case management services program, did not fail to act as required by law or rule, did not fail to use proper procedure, did not act erroneously, nor did it exceed its authority or jurisdiction.
DECISION
Based on the foregoing Findings of Fact and Conclusions of Law, Petitioner SETAPART, properly was denied re-certification as a case management service provider.
ORDER AND NOTICE
The North Carolina Department of Health and Human Services will make the Final Decision in this contested case. N.C. Gen. Stat. §150B-36(b), (b1), (b2) and (b3) enumerate the standard of review and procedures the agency must follow in making its Final Decision and adopting and/or not adopting the Findings of Fact and Decision of Administrative Law Judge.
Pursuant to N.C. Gen. Stat. §150B-36(a), before the agency makes a Final Decision in this case, it is required to give each party an opportunity to file exceptions to this decision, and to present written arguments to those in the agency who will make the Final Decision. N.C. Gen. Stat. § 150B-36(b)(3) requires the agency to serve a copy of its Final Decision on each party and furnish a copy of its Final Decision to each party’s attorney of record and to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, NC 27699-6714.
This the 16th day of February, 2006.
______
Beecher R. Gray
Administrative Law Judge