Balderas Releases 2013 Health Audit, With Redactions

Jan 30, 2015

Weeks after taking office, new Attorney General Hector Balderas released on Thursday the remainder of the 2013 audit of 15 New Mexico behavioral health agencies, albeit with some redactions.

Thursday was the first time the public saw most of the audit. The previous attorney general, Gary King, released portions relating to two of the 15 organizations last year after his office completed investigations into potential Medicaid fraud and cleared those organizations. King refused to release the rest of the audit, saying doing so would compromise his office's ongoing criminal investigations.

A judge in a separate case brought by the N.M. Foundation for Open Government ordered a portion of the audit related to a third behavioral health organization released in December. The rest of the audit - hundreds of pages - remained secret until Thursday.A judge in a lawsuit brought by New Mexico In Depth and the Las Cruces Sun-News allowed King to keep the rest of the audit secret.

No definitive answers

The audit does not provide definitive answers to the most-asked questions over the past 19 months.

For instance, the document does not offer conclusive evidence that there is probable cause to believe the organizations committed Medicaid fraud. That determination can only come from law enforcement following an investigation.

But that wasn't part of the Human Services Department’s June 2013 announcement that it had frozen Medicaid funding to each of the 15 New Mexico health organizations. The department said it based its decision in part on the preliminary findings of the state-commissioned audit that showed the 15 agencies had potentially overbilled Medicaid by a combined $36 million.

Over the past year, scrutiny has thrown into question that eye-popping figure as well as the thoroughness of the state-commissioned audit. When then-AG King's office cleared two of the 15 organizations of fraud allegations, his office said the audit overestimated the number of Medicaid claims believed to be questionable.

And in December, for the first time publicly, the Massachusetts firm that performed the audit, Public Consulting Group Inc. (PCG), said it didn’t follow its normal procedures in New Mexico and give the 15 health organizations a chance to respond to allegations before finalizing the audit's findings.

Giving organizations a chance to analyze preliminary findings is a common practice for auditors. Running the information by staff at the targeted organizations lets them refute findings or address misunderstandings. It’s a way of ensuring the accuracy of an audit, among other things.

A PGC spokesman didn't tell NMID why it didn't disclose preliminary findings to the 15 New Mexico health organizations. An HSD spokesman blamed then-AG King's office, but it was a decision by HSD, not the AG, that triggered the criminal investigation.

Whatever the case, PCG's refusal to disclose preliminary findings to the 15 organizations kept those organizations in the dark about details of the allegations they faced. It also deprived them of the opportunity to respond to PCG’s findings and correct any misunderstandings or inaccuracies.

Instead, in June 2013, saying it was relying on PCG”s preliminary findings, HSD froze Medicaid dollars to the 15 New Mexico organizations. The HSD went on to accuse the New Mexico organizations of “credible allegations of fraud” and asked law enforcement to investigate.

That decision has been catastrophic for many. Accused of overbilling and potential fraud, their Medicaid funding frozen, many of the 15 organizations closed. Others are barely hanging on.

Meanwhile, tens of thousands of their clients – some of the most vulnerable New Mexicans, needing treatment for issues such as suicide attempts, depression and drug addiction – found themselves caught up in a chaotic transition as the state brought in five companies from Arizona to try to fill the void created when the New Mexico organizations shut their doors.

Another transition on the horizon

Southeastern New Mexico might soon find itself going through a second chaotic transition.

Turquoise Health and Wellness, one of the companies brought in by Gov. Susana Martinez’s administration to take over for the accused New Mexico organizations, will cease operations March 31.

Turquoise offers mental health services to Medicaid patients in cities including Roswell, Carlsbad, Clovis and Tucumcari. When Turquoise leaves it’s unclear who will pick up the pieces -- or who will care for the area's vulnerable population.

“I’m here saying, ‘We don’t have alternatives,’" Roswell Mayor Dennis Kintigh told New Mexico In Depth earlier this week.

Kintigh, a former Republican state lawmaker, was in Santa Fe to talk to his former colleagues in the Roundhouse about the Turquoise situation.

Roswell is a city of more than 48,000 less than an hour's drive from the Texas border. Kintigh said the loss of a provider wouldn't leave a larger city like Albuquerque without options. The situation is different in Roswell.

“I don’t know who to turn to," Kintigh said.

Proposed legislation

In the next two months, New Mexico’s state lawmakers likely will take up legislation that would require the state of New Mexico to share allegations of wrongdoing with a targeted health care provider and give it a chance to respond before it can impose punitive measures.

When asked for her opinion on the concept earlier this week, the governor declined to say whether beefing up protections is a good or bad idea.

“I haven’t read it,” Martinez said of the legislation. “Nothing has come to my desk yet. You know how it works. It’s going to be changed (by the Legislature) at least 10 times by the time it gets to my desk.”

Earlier this month, a Santa Fe judge ruled that the HSD had denied due process of one of the 15 providers accused of fraud that operates in Northern New Mexico. The judge ordered the department to hold a hearing that would allow Santa Fe-based Easter Seals El Mirador to hear the specific allegations against it for the first time — and give the provider a chance to respond to those claims.