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New Mexico behavioral health provider faces overbilling charges, but questions remain

With audit only partially released, provider argues that $4 million claims in question were properly billed

A portion of a 2013 audit investigating the billing practices of a New Mexico nonprofit behavioral health provider reveals more than $4 million in overbilling based in a case-by-case review of 150 claims, according to the Albuquerque Journal.

The audit was released by New Mexico Attorney General Gary King following a district judge's decision, the Journal reported in December. The portion of the audit that was released to the public shows that Santa Fe-based Presbyterian Medical Services overbilled 41 of 150 reviewed claims. The Massachusetts-based audit firm, Public Consulting Group (PCG), could not find documentation that drug tests and other services had been conducted, or that some nonprofit staffers did not have the necessary qualifications.

Questions remain regarding the legitimacy of these findings. The state based its fraud allegations on incomplete record keeping of mental health treatment providers, rather than on false Medicaid billing claims, according to the Santa Fe New Mexican. Presbyterian settled with the state in 2013 for $4 million--but facility administrators claim the prospect of a lengthy legal battle, and possible closure, forced them into the settlement.

 "[Presbyterian] believes the state of New Mexico and the Human Services Department have an appropriate and important role in investigating potential fraud and abuse in the Medicaid program," Don Daniel, an attorney for Presbyterian, told The New Mexican. "We just feel that this particular PCG audit process was incredibly flawed."

Presbyterian was one of 15 providers included in the full audit. Many were stripped of their Medicaid funding. "A handful" of those providers have filed lawsuits against the Human Services Department, according to The New Mexican. The 2013 settlement prevents Presbyterian from suing the state over fraud allegations.

For more:
- read the first and second Albuquerque Journal article
- here's the Santa Fe New Mexican story

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Feds crack down on therapeutic services fraud