Alliance Compliance Team Stands Strong against Fraud, Waste and Abuse

Matt Ruppel

Matt Ruppel, Senior Director of Program Integrity

Alliance Health’s commitment to delivering high-quality services at a sustainable cost to the people we serve includes robust, proactive efforts to promote compliance and ethics among Alliance staff, providers and members.

“Compliance and ethics lay the groundwork for what we can and should do, how we should behave, and how we should interact with each other, the members we serve, and our providers,” said Matt Ruppel, Senior Director of Program Integrity.

Ruppel said one way to understand these concepts is that compliance will tell you what you can do, per laws and regulations, and ethics are what you should do. “One isn’t any more important than the other, they both hold the same value as far as I’m concerned,” he said.

A large part of our effort is a serious and proactive commitment to minimize the impact of fraud and abuse in the Medicaid system. “Every dime, every penny we lose to fraud, waste, and abuse is that much less money that is available to help our members get legitimate services,” Ruppel said.

In healthcare, fraud is when someone intentionally lies to an insurance company, Medicaid or Medicare to get money, waste is when health services are carelessly overused, and abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.

Ruppel said healthcare anti-fraud groups report that about 10 percent of all money spent on healthcare is fraudulent, which can amount to billions of dollars across all commercial health plans, Medicaid and Medicare. “So anything we can do to prevent it is the most important thing,” he said.

“We spend a lot of our time recovering money, and investigating things that seem like they went wrong,” Ruppel said. “And the best thing we can do is prevent it from going out in the first place. Because once you pay that money out, it’s hard to get it back.”

To uncover fraud, waste and abuse, Ruppel’s team uses claims audits and data analytics to help identify aberrant billing that could signal wrongdoing, carelessness or lapses in oversight. They also rely on tips or alerts from Alliance staff or others involved in member care.

“The more that our employees can be educated about it, the more they can recognize an issue and say something if they see something,” he said. “And we want people to say something even if they’re not sure if it’s fraud. If you think it’s not right, report it, we’ll investigate it and figure it out.”

Ruppel’s team, the Special Investigations Unit, follows up on tips and alerts with diligent detective work, poring over records, reviewing provider monitoring data and interviewing staff, members and providers. When they determine that fraud has likely occurred, they refer the case to the NC Medicaid Office of Compliance and Program Integrity. If that office decides it’s a credible case, they send it to the Medicaid investigations division for criminal and civil investigation.

In some cases the unit’s investigations reveal that suspected fraud is actually the result of carelessness or shoddy practices by provider staff. “We often see bad controls and providers with an employee or maybe several employees that are cutting corners,” Ruppel said. The compliance team works with those providers to help them understand why they need to develop better controls and educate their staff.

Ruppel said that individuals can do their part to prevent healthcare fraud by safeguarding their health identity and their member number. “The best advice I can give is to treat it like a credit card, don’t just give it out,” He said.

He also advised to not sign documentation that is not complete or that you do not understand, and to always date anything you sign. “We will find treatment plan and signature pages where the guardian has signed it but there’s no date. So then that becomes the template that the provider will use whenever they need a signature page updated,” he said.

Learn more about Medicaid fraud and abuse at the Alliance website.

New Pharmacy Director Added as Alliance Expands Scope

Dr. Neal Roberts

Dr. Neal Roberts

Neal Roberts, PharmD, has joined Alliance as our new Pharmacy Director. Most recently, Dr. Roberts was the Pharmacy Clinical Coordinator for the Northwest Community Care Network, where he monitored the clinical pharmacy services for 140,000 Medicaid members within the northwest NC counties. In a prior role, he developed and managed the pharmacy benefit for a health plan serving over 30,000 individuals.

Dr. Roberts’ primary responsibility at Alliance will be directing the company’s pharmacy benefit and collaborating with our Tailored Plan pharmacy benefit manager, Navitus Health Solutions. According to Mehul Mankad, MD, Chief Medical Officer at Alliance, “Pharmacy benefits management forms the third vital component of our Tailored Plan strategy – with mental health benefits and physical health benefits as the two other critical elements. We are delighted to have Dr. Roberts join the Alliance team.”

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Cumberland Recovery Response Center Holds Open House

Left to right: District 19 State Sen. Kirk deViere, Cumberland County Board of Commissioners Vice Chairman Glenn Adams, Alliance Health CEO Rob Robinson and N.C. Division of Mental Health Director Victor Armstrong.

Left to right: District 19 State Sen. Kirk deViere, Cumberland County Board of Commissioners Vice Chairman Glenn Adams, Alliance Health CEO Rob Robinson and N.C. Division of Mental Health Director Victor Armstrong.

After a year-long delay due to COVID-19 restrictions, the Cumberland Recovery Response Center held an open house this week.

Formerly known at the Roxie Center, the Cumberland Recovery Response Center provides a range of services for people experiencing mental illness and substance use disorder. The facility underwent renovations beginning in 2019 and opened under the management of RI International in May 2020. It has already provided services to more than 1,400 people.

The center offers behavioral health urgent care and a 10-chair, 23-hour observation unit where individuals are assessed by a psychiatric nurse practitioner or physician’s assistant to determine their needs. State approval is pending for a 16-bed crisis unit.

The center is staffed by mental health and medical professionals as well as  peer support staff who have life experiences with crisis situations. It offers services 24/7 to people 18 and over who are experiencing a crisis. First responders may drop off patients experiencing a mental health or substance abuse crisis directly at the recovery response center instead of a hospital emergency room.

“I want to thank the Cumberland County Board of Commissioners for their ongoing commitment and funding to behavioral health services,” said Alliance Health CEO Rob Robinson. “The funding they provide is critical to provide service individuals who are uninsured or do not have the means to pay.”

Community Members tour the Cumberland Recovery Response Center during the Open House on July 19.

Community Members tour the Cumberland Recovery Response Center during the Open House on July 19.

Glenn Adams, vice chairman of the Cumberland County Board of Commissioners and a member of Alliance Health Board of Directors, said the center “has been a labor of love and something truly needed for our community. It is about collaboration and all of us working together to make sure we meet the needs of the underserved and those in our community.”

CRRC is one of the facilities operated in the four-county Alliance Health service area that is designed to provide a clinically appropriate, community-based option to help stabilize those in behavioral health crisis without a hospital emergency department or inpatient setting.

RI International is a national leader in developing and providing recovery-oriented behavioral health and substance use disorder crisis services. It has been operating crisis assessment and stabilization services since 1990.

A video of the open house ceremony is available on Cumberland County’s YouTube channel.

Alliance to Observe Juneteenth as Holiday

In recognition of the importance of Juneteenth to our employees and the communities we serve, Alliance Health recently added Juneteenth as an observed holiday starting in 2022.

Juneteenth is an annual commemoration of the announcement of freedom for enslaved people in Texas on June 19, 1865, following the American Civil War.

“The significance of this holiday has been acknowledged and celebrated by many in recent years, culminating this year with the federal government making it a national holiday,” said Alliance CEO Rob Robinson. “At Alliance Health, we also recognize the importance of Juneteenth and how freedom was declared and claimed with the pronounced end of slavery.”

In addition to closing its offices, Alliance Health with share information about the history of Juneteenth as well as opportunities for employees to observe the important day in their communities.

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IAAP Honors Alliance’s Veronica Ingram

Veronica IngramThe International Association of Administrative Professionals (IAAP) has honored Alliance Executive Assistant Veronica Ingram with the 2021 Achievement Award, which recognizes contributions and achievements that exemplify IAAP’s vision, purpose, and values.

Ingram has been a member of IAAP since 2016 and served three terms as the branch director for the RTP area. She now serves as the region director for North and South Carolina and on IAAP’s DEIC. She has been with Alliance since 2013, beginning as an Office Assistant for Compliance before being promoted to Executive Assistant to the CEO later that year.

IAAP is an almost eighty-year-old professional association with more than 7,500 members. It is focused on professional development, networking and elevating the administrative profession. One of the most well-known ways they’ve advanced administrative professionals is collaborating with the federal government to create Administrative Professionals Day in April.

Alliance Health Receives NCQA Accreditation

Alliance Health, the Medicaid Managed Care Organization (MCO) for Cumberland, Durham, Johnston, and Wake counties in North Carolina, has earned Full Medicaid Managed Behavioral Health Organization (MBHO) Accreditation with a Long-Term Services and Supports (LTSS) Distinction from the National Committee for Quality Assurance (NCQA).

Alliance is one of three MCOs in North Carolina to earn a full three-year accreditation and only the second MCO to earn LTSS Distinction. Full accreditation is granted for a period of three years to those plans that have excellent programs for continuous quality improvement and meeting NCQA’s rigorous standards.

NCQA MBHO Accreditation is a nationally-recognized evaluation that purchasers, regulators, and consumers can use to assess MBHOs. NCQA MBHO Accreditation evaluates how well a health plan manages all parts of its delivery system – practitioners and provider organizations – in order to continuously improve care for its members. NCQA reviews include rigorous on-site and off-site evaluations conducted by a team of managed care experts. A national oversight committee of physicians and behavioral health providers analyses the team’s findings and assigns an accreditation level based on the MBHO’s performance compared to NCQA standards.

“Alliance Health’s MBHO Accreditation is proof that it’s an organization which works hard to coordinate care, provide access and good customer support for members,” said Margaret E. O’Kane, NCQA President. “It’s a sign that Alliance is focused on improving the behavioral health of its members.”

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in informed health care. NCQA’s website (ncqa.org) contains information to help consumers, employers and others make more-informed health care choices. NCQA can be found online at ncqa.org, on Twitter @ncqa, on Facebook at facebook.com/ncqa.org/, and on LinkedIn at linkedin.com/company/ncqa.

NCDHHS Update on Tailored Plan Beneficiaries

From NCDHHS:

During the Open Enrollment period, the Department closely monitored data indicating the active selections of Tailored Plan-eligible beneficiaries into Standard Plans. None of these beneficiaries were auto-enrolled in a Standard Plan. Toward the end of Open Enrollment, there was an increased uptick in the number of Tailored Plan-eligible beneficiaries who enrolled in a Standard Plan.

  • Through June 1, approximately 7,000 Tailored Plan-eligible beneficiaries made an active selection to enroll in Standard Plans, which may make them ineligible for services they are currently receiving, have recently received, or may benefit from receiving.

Based on the number and profile of Tailored Plan-eligible beneficiaries who enrolled in a Standard Plan, the Department determined that these beneficiaries would benefit from receiving additional information to ensure they are fully aware of the impact of the decision to leave NC Medicaid Direct and their LME-MCO and enroll in a Standard Plan — including the potential loss of services.

Therefore, the Department will stop Standard Plan enrollments of these beneficiaries and all Tailored Plan-eligible beneficiaries who selected a Standard Plan will remain in NC Medicaid Direct and their LME-MCO through NC Medicaid Managed Care Go-Live on July 1, 2021.

The Department will provide additional information to ensure that these beneficiaries are fully aware of services that may be lost if they move to a Standard Plan. This will include a notice to be sent later this month informing them of the change back to NC Medicaid Direct as well as a detailed list of services that are not available in a Standard Plan.

Beneficiary choice remains paramount and Tailored Plan-eligible beneficiaries will still have the option to enroll in a Standard Plan. The Department plans to implement, by early August, a specific enrollment process for Tailored Plan-eligible individuals that will include enhanced choice counseling to help verify that beneficiaries have all the information they need to understand the impact of their decisions.

We will continue to provide updates on this process and appreciate your ongoing partnership in serving the state’s Medicaid beneficiaries and their families.

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Joint Alliance Health/Cardinal Innovations Healthcare Statement Regarding Mecklenburg County LME/MCO Realignment

On June 1, 2021, the Mecklenburg Board of County Commissioners (BOCC) unanimously voted with one abstention to disengage from Cardinal Innovations Healthcare and realign with Alliance Health. On June 3, 2021, the Alliance Board of Directors voted unanimously to move forward in negotiations with Mecklenburg County as a member county of Alliance Health.

Mecklenburg County’s primary focus regarding this realignment is to carry out the process with transparency, commitment to the community, and involvement of those who will be impacted by the change. The county, Alliance, and Cardinal are committed to working collaboratively to ensure a smooth transition for all involved. The BOCC authorized the county manager to issue a letter of intent, develop a disengagement realignment plan, and notify the affected counties within the organizations’ catchment areas. Those and other related documents are posted on the county’s website at https://www.mecknc.gov/Realignment/Pages/Home.aspx.

“I am very appreciative of and honored by the confidence Mecklenburg County has shown in Alliance,” said Rob Robinson, CEO of Alliance Health. “We are eager to begin engaging with local organizations, public partners, and behavioral healthcare providers in the county to build a community-based system of care to address social and environmental factors that impact the overall health and quality of life of individuals and families who are enrolled in Medicaid or uninsured. As this process begins, I would also like to thank Cardinal CEO Trey Sutten and the Cardinal Board for their commitment to work with us and the county throughout this transition to prevent any disruption in services for members and providers.”

“Our highest priority is the stability and health of our members in Mecklenburg County and the hundreds of employees who serve them every day,” said Trey Sutten, CEO of Cardinal Innovations. “We will continue to work closely with DHHS, Alliance, and Mecklenburg County throughout the process.”

Alliance Honors People and Agencies who Make a Difference in our Communities

Each May, in honor of Mental Health Awareness Month, Alliance Health recognizes people and organizations who have made extraordinary efforts to improve life in their communities with our Making A Difference Awards. Below is information about this year’s honorees in each of the counties we serve.

Cumberland County:

The Cumberland County Department of Public Health was honored because of exceptional efforts to provide services to the community during during the COVID-19 pandemic. The agency provided current information and safety measures on COVID-19 for its staff and the community, and conducted a community-wide vaccine drive-through when the vaccine was made available.

The Emergency Department of Cape Fear Valley Medical Center was honored for extraordinary efforts on behalf of Cumberland County citizens. The Emergency Department was a life saver to many people with COVID-19 and the staff demonstrated amazing professionalism, kindness and respect to people in their care.

Durham County

Armenous Dobson receives his Making a Difference Award from Ashley Bass-Mitchell

Armenous Dobson, left, Program Specialist for Insight Human Services, receives his Making a Difference Award from Ashley Bass-Mitchell

Armenous Dobson III, a Program Specialist for Insight Human Services as well as a husband and father, was honored for being a leader in the community, an advocate of hope, and a voice of positivity. Mr. Dobson is always open, honest, transparent and present in meetings and takes on many leadership roles with in the community while also working with youth in our schools to provide them with resources and mentorship.

James Keaton, the Director of School Nutrition Services for Durham Public schools, was honored for his tireless efforts before and during the pandemic to make sure that Durham Public School youth are nutritiously feed. During the pandemic he stepped up even more to close food gaps for our students and families, kept the community abreast regarding the accommodations made for families to receive food, and set up volunteer opportunities.

Rodney Jenkins, Health Director of the Durham County Department of Public Health, receives the department's Making a Difference award

Rodney Jenkins, Health Director of the Durham County Department of Public Health, receives the department’s Making a Difference award from Ashley Bass-Mitchell.

Durham County Department of Public Health, which has always been a place of resources, connections and ensuring the wellbeing of individuals, youth and families, was honored for stepping up to help the community navigate through the public health crisis caused by the COVID-19 pandemic.

Duke Regional Hospital Emergency Department was honored for  their efforts to compassionately and thoroughly provide services to individuals, youth and families within the community. This life saving group often works behind the scenes to ensure that those in crisis and enduring an array of challenges are still met with understanding and care, no matter the circumstances.

Welcome Baby staff receive their Making a Difference Award

Welcome Baby staff receive their Making a Difference Award from Ashley Bass-Mitchell.

Welcome Baby, which provides parent support programs and other resources for families with children aged 0-5, was honored for their extra efforts during the pandemic crisis to help fulfill community needs and offer support to families in the community.

Duke University Hospital Emergency Department, an already very busy Level 1 trauma center, was honored for their extra efforts during the pandemic to care for those in need, even at a risk to themselves. They also created a safety net of care and for families that could not be with their loved ones during some of the most vulnerable times in their lives. They rose up and met head-on the unfamiliar Covid19 challenge. https://www.dukehealth.org/locations/duke-university-hospital-emergency-room

Johnston County

Johnston County Making a Difference Award honorees

Johnston County Making a Difference Award honorees.

Dr. Amanda Allen, the Director of Social and Emotional Learning for Johnston County Public Schools Student Services & Office of Equity, Information and Student Services and the Chair of the Johnston County Community Collaborative, was honored for the tireless efforts she and her staff make on behalf of children and families throughout Johnston County.

Johnston County Emergency Services, which provides leadership and support to minimize the impact of disasters and other emergencies, was honored for rising above and beyond their mission to care for those most in need during the Covid19 pandemic.

The Johnston County Public Health Department, known as the “physician for the community,” was honored for rising to the challenge of carefully, strategically and safely navigating the community through the COVID-19 pandemic.

Wake County

Oak City Cares, which provides comprehensive supports to help people address basic needs and access services they need to move out of homelessness, was honored for their ongoing service to Wake County residents who are experiencing or are at risk for homelessness. Despite the challenges of the COVID-19 pandemic, from March 2021-November 2021, Oak City Cares served 730 Wake County residents with weekday services and provided 25,000 meals through their weekend meals program.

Teneisha Towe

Teneisha Towe

Shea Cleveland

Shea Cleveland

Teneisha Towe and Shea Cleveland, who have served as Chair and Co-Chair of the Wake County Community Collaborative for Children and Families since 2014, were honored for their ongoing service to Wake County. Under their leadership, the Wake County Collaborative did not miss a beat during the COVID-19 pandemic and quickly adapted to a virtual world, ensuring that the collaborative’s work continue during the challenging time.

Wake County Public Health was honored for rising to meet unparalleled challenges in the face of the COVID-19 pandemic, responding nimbly and efficiently to address the quickly changing health crisis.

The Emergency Department of Wake Med Hospital was honored for their tireless work for the health and safety of Wake County residents during the COVID-19 pandemic. While pandemic effects have been pervasive, emergency departments have shouldered an outsized share of the burden.

Alliance Community Liaison Dispenses Hope at Oak City Cares

Oak City Cares LogoWhen people walk into Oak City Cares in Raleigh, a safe place to stay is usually just one of many things on their list of needs. Alliance Community Liaison Dave Mullin is one of the people there to connect them with organizations and resources that can help.

Oak City Cares is a hub designed to provide, under one roof, connections to coordinated services for people experiencing or at risk of homelessness and help them create a path to stable housing and renewed hope. “It’s a collaborative, integrated healthcare model that everything in healthcare these days is aspiring to be,” Mullin said.

The facility, which is unique in North Carolina, was created by Catholic Charities of the Diocese of Raleigh in partnership with Wake County, the City of Raleigh and the Raleigh-Wake Partnership to End and Prevent Homelessness.

Alliance Health Community Liaison Dave Mullin photo

Alliance Health Community Liaison Dave Mullin

Mullin, who also manages the Wake Network of Care, a comprehensive directory of services, organizations, and supports throughout Wake County, has worked with Oak City Cares three days a week since it opened its doors in April 2019. He serves as a “front-door” to services, working to connect guests with the help and resources they need to plan their exit from homelessness.

Sixteen different providers are represented at Oak City Cares, offering medical assistance, behavioral health care, veterans’ services, outreach, employment services, coordination of care and support. Guests can access showers and laundry, a hospitality area with coffee, computers, and cell phone charging stations. Meals are also offered on weekends. While COVID-19 drastically curtailed services inside the building, the center is slowing reopening to guests now that restrictions have been loosening.

Mullin said he typically meets for about an hour with guests who are referred to him and builds a relationship with them. “We talk about the various things going on in their life, and probably 85% of that is around housing.” He works to connect them with a shelter or, if possible with family and friends or other available natural supports in their lives. (Before the pandemic his work was all onsite, but he is currently meeting virtually with people because of restrictions.)

Housing is usually just the most immediate of many needs people are facing when they arrive. “I try to assess as we’re talking what it is that they’re looking for, and I try to meet that either onsite or if necessary, tell them what agency is going to be able to help them in the community,” he said. “If they need clothing, if they need food, if they need a bus pass, if they need prescription payment assistance, if they need domestic violence resources, whatever the particular issue is, I look at the person as a whole person,” and not just someone who needs a place to sleep, he said.

Mullin, who has two master’s degrees in clinical pastoral counseling and patient counseling and has worked for many years in the mental health field, said his experience is very helpful when guest is in crisis and may need help de-escalating.

“I’ve worked with homeless people for a long time and what I’ve found is that the biggest reason people are homeless is because of loss,” he said. “You know, they’ve lost a relationship, they’ve lost their health, they’ve lost their home, they’ve lost their job, they’ve lost sobriety, they’ve lost mental health, whatever the loss is, that’s a precipitating factor in someone becoming homeless.”

Most people facing homelessness have also experienced “a pretty traumatic life along the way,” he said. “So whenever someone comes and sits in a chair with me, I want to give them respect, I want to listen to them. I want to treat them with dignity and care, I want them to feel like they matter. Because the biggest complaint I’ve ever heard throughout my years has been that homeless people feel invisible. No one cares about them, no one thinks about them, no one looks at them, they feel like they are nothing. I want to give them the sense that they are someone, and they’re important to me.”

Mullin said his most important goal is to instill hope in people. “I’m not going to be able to fix their lifelong issues, and I’m not going to be able to put them into a nice apartment that day. I’m going to sit there and work with them on a plan for housing, whatever the need is, I’m going to hopefully be able to get them connected with some other things that will enhance their life. My goal with each and every person is to have that person leave feeling a little bit better and with something in hand to show that our time together was valuable and they are valuable.”