NYS Department of Health numbers released at last week’s meeting of the TBISCC (Traumatic Brain Injury Services Coordinating Council) reveal that TBI Waiver providers across the state may not be getting paid for nearly 11 percent of those individuals on the waiver. The DOH figures for March reveal that while there were 2,839 people were on the waiver, only 2,527 were billed for and 312, or 10.98 percent to be precise, were not.
In every region in the state it appears waiver providers are doing significantly more work than they are getting paid for, a fact the DOH was and is quick to blame on anyone but the DOH. Some of the numbers are staggering. In New York City it seems providers are not getting paid for nearly 22 percent of those on the waiver with 374 enrolled and only 293 getting billed for. In Long Island providers were not paid for 14.2 percent of their waiver participants and in the Binghamton/Southern Tier region they were not paid for 12.29 percent.
While TBISCC chair Michael Kaplen pressed DOH officials at the meeting for an explanation of the numbers’ discrepancies, both Kaplen and DOH Official Maribeth Gnozzio speculated that the reasons for the discrepancies in the numbers may the responsibility of anyone but the DOH itself. Gnozzio was more generous with her finger pointing, placing the reason for the discrepancies at nearly everyone’s feet but the DOH’s. She blamed the counties, delays in billing, lapses in service coordination, and fair hearings. Kaplen, on the other hand, speculated that the reasons may some are on the waiver who don’t need to be and others may not getting waver services. However, Kaplen made it clear the issues was a significant one when he said, “This is a huge number to go unaccounted for.”
Kaplen said, “If you have a discrepancy, and I’m just going to use Syracuse (with) approximately 40 individuals (that providers have not been paid for), it means… it could mean that some of these individuals don’t need services and that’s why there’s no billing and they really should be examined to determine whether or not they need to be on the waiver. It’s also possible being that some of these individuals need services and are not getting services and that’s why there’s no billing taking place. But I think there would be important to look at both of those items.”
This writer can tell you that he cannot remember single instance of a provider refusing to give services to a survivor. Moreover, both Gnozzio and Kaplen failed to mention what may well be the primary reason for the differences in the enrollment and billing numbers. When CMS (Centers for Medicare & Medicaid Services) recently audited the state’s waiver, they made it clear that providers could not bill until the received signed approval in the form of an NOD (Notice of Decision) from the DOH. Sources from around the state make it clear the DOH is often slow off the mark in signing NODs and some, including this writer, think at times this may be by design. Providers are only allowed to back-bill 90 days. So, if the NOD takes four to five months to get signed by the DOH, the providers lose one to two months of revenue they’ve truly earned.
The following are the regional numbers provided in the chart provided to the TBISCC by the DOH:
Syracuse: 321 enrolled, 287 billed for.
Rochester: 492 enrolled, 463 billed for.
NYC: 374 enrolled, 293 billed for.
Lower Hudson Valley: 236 enrolled, 212 billed for.
Long Island: 246 enrolled, 211 billed for.
Capital District: 356 enrolled, 324 billed for.
Buffalo: 273 enrolled, 257 billed for.
Binghamton/Southern Tier: 301 enrolled, 264 billed for.
Adirondack: 240 enrolled, 216 billed for.