ACCESS PEAK
HOW UNITED HEALTHCARE BOUGHT ACCESS TO THE GOVERNOR, WON LUCRATIVE CONTRACTS WITH
During the heat of her first gubernatorial campaign,
A day before NMPolitics.net published the column, Martinez attended a meeting at
And afterward, the company cut a
The check came, the source says, with a personal thank you note from a
"We enjoyed meeting with you," read the note from the head of the corporation's state government lobbying divison, "and look forward to seeing you again soon in
With swipes of a pen, an insurance company executive in the nation's capital had given to a state party in
And
"We need a new direction in state government," Martinez proclaimed in the column, "one that has zero tolerance for pay-to-play deals for affluent special interests."
An SFR investigation of the relationship between the
On
State officials refused to show those providers, and the public, the
Almost two years after that decision, which affected up to 85 percent of the state's behavioral health spending and 30,000 patients being treated for those services, none of those providers have been criminally charged with fraud. Two of them have been cleared of criminal wrongdoing after the attorney general said overpayments of
Patients from
Records show
Following Martinez' historic election,
HSD spokesman
State officials bristle at the notion that the insurance industry had more sway than New Mexicans in the redesign.
"HSD held seven meetings statewide with more than 674 people in attendance, two tribal consultations with over 229 tribal representatives in attendance, eleven meetings with individual Native American groups or individuals throughout the state, a legislative meeting and hearing, four workgroups that met over 16 hours each with 66 people participating [including advocates]," reads Kennicott's written statement, "and a dedicated phone hotline, email, and snail mail where more than 94 comments were received, including 7 tribal position papers and positions papers from advocate groups."
McCleskey would not comment for this story. A spokesman for the
"Like any company, we regularly meet with our customers to discuss the status of our work and ways we can evolve our partnership to best meet the needs of the people they serve," Optum spokesman
Both
A DECADE OF SHAKEUPS
Martinez' redesign of
Under Johnson, who served on the Fourth Floor from 1995 to 2003,
Through the Johnson arrangement, the insurers began denying and delaying coverage to one of the most expensive patient populations in their networks: those receiving behavioral health care treatment.
"The MCOs are in business to make money," even today, says
When Richardson took office,
"People with mental illness felt empowered for the first time to have some say in what is often a system that makes choices for them," says
The state established local behavioral health groups across the state to advise the New Mexico Interagency Behavioral Health Purchasing Collaborative- composed of 15 state agencies that provided mental health treatments in various capacities. Officials encouraged patients and others to participate in the local groups, which would advise the decision-making state collaborative about the unique health care needs of each region. Those in a rural area of the state, for instance, might need transportation services to get to far-flung providers.
"It was a great idea," says
Yet research found politics made its way into the local groups. State officials didn't always listen to the recommendations or provide enough financial support for the various administrative tasks they required. Eventually, participation dropped off.
While the statewide collaborative shaped policies and procedures, it contracted with one company under a managed care arrangement to administer
The approach kept behavioral health
State officials, following concerns about Value Option's performance, selected Optum for the roughly
OPTUM SCRUTINIZED
Compare those fines to
Kaiser's data doesn't include sanctions
Problems with Optum didn't stop there.
On
But just weeks later, providers discovered its implications: Optum began cutting payments to them for outpatient services for the mentally ill meant to help them with life-coping skills. Optum's imposition of "clinical triggers"-demanding that providers justify the services before being paid for them-had been unilateral.
Officials went as far as saying Optum misled them about the change that resulted in denial of more than
"Under
Providers also say Optum wasn't always the most diligent auditor.
"
"The monitoring shall include regular provider reviews," reads the Optum contract, as well as "on-site audits to determine provider compliance with clinical and non-clinical requirements."
Optum spokesman Lotterman wouldn't address that charge but defends the company using a familiar phrase: "We consistently fulfilled our contractual responsibilities, including helping people get the most appropriate care and reporting potential instances of fraud, waste and abuse to the state for further investigation."
OPTUM TURNS THE TABLES
Martinez' campaign, in the spirit of transparency, would release a list of the private donors to a committee that financed the governor's inaugural celebrations. The usual benefactors, like energy companies, contributed. Yet one donor that had never appeared on her campaign reports made a hefty contribution:
A month later, The
The administration began to gear up to fundamentally revamp its
In
The RGA raises and spends unlimited amounts of cash from its corporate and individual benefactors, like
Hurricane Irene caused the RGA to reschedule the summit, but its policy committee still organized a survey for state officials to assist in the association's "networking efforts" with RGA members.
On
"Fraud, waste and abuse."
The results of the RGA's questionnaire to state officials would be a
A report to
But Romero says that "never did we get denials" of any of the billing codes they'd entered into the new software. She says Optum was "setting up a false sense of security."
In March, while Optum showed up at the 15 agencies to audit books with officials from the
More than 50 corporate representatives whose companies contributed
For Sunday evening, the first day of the trip, officials scheduled cocktails followed by a buffet-style dinner at the
In an interview in December, after she lefther post, Squier said she didn't recall the specifics of the retreat. Cell phone records confirm she was in
But Squier made at least one relevant connection. On
Cowen wanted to know if Squier would be willing to meet with Cowen and
When Cowen opened
Monday morning at 11 "works best," Cowen said, replying to Squier. "By the way," he wrote, "on a totally separate matter, does [
Just ten days later, the state submitted its Centennial Care plan to the feds, stressing that it sought to deliver
Like
In the coming moths, Squier's HSD unveiled Centennial Care, and on
By October, Optum alerted HSD officials that it had flagged suspicious billing activity of behavioral health providers. In an already widely publicized email to an HSD official, Optum CEO
"For example," she wrote, "OHNM has in its
The publication of Martin's email by media outlets in
But there's a less-quoted line at the end of the email. It's Martin making a pitch to the HSD official that "in the long term," Optum, whose contract with the state was set to expire, "has the capability" to ensure program integrity for billings.
"Optum's state-of-the-art fraud, waste and abuse detection and prevention capability is a leader in the nation," Martin wrote, "and has been specifically tailored to the NM system."
In December, Optum announced that it had partnered with a
The Tar Heel State had previously hired SAS to audit its own
"This was a result somebody already wanted to come to,"
Five days before responses to that Centennial Care bid were due, Edwards and
In January of 2013, HSD awarded the four Centennial Care contracts to cover
In May of 2014, the
HSD officials, meanwhile, had to figure out which contractor would administer non-
The 18-month agreement gives Optum the responsibility of handling
The 15 New Mexico providers, none of which have been criminally charged as a result of the audit, weren't so lucky. Many are still out of business. A month after the fraud allegations, Martin had a "chance meeting" at a
The shakeup strained that relationship. Martin wrote a
"We have always worked [with you] on claims and getting necessary documentation," Freedle reportedly said. "Why is this different?
"Now you drop in a whole new snoop and sniffsystem and 15 [providers] are crooks?" Freedle said. "Bullshit. You got it wrong.''
"Like any company, we regularly meet with our customers to discuss the status of our work and ways we can evolve our partnership to best meet the needs of the people they serve."
"This was a result somebody already wanted to come to."
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