Experts Confirm Industrywide Interpretation of Medicaid Billing for Personal Care Services

RALEIGH, N.C., July 18, 2017 /PRNewswire/ -- Leaders in the long-term care industry, including Affinity Living Group, weighed in today on the industrywide interpretation of Personal Care Services (PCS) billing to Medicaid. Recently, this issue was raised by a court action questioning how Medicaid reimbursement is documented by assisted living providers in North Carolina. The lawsuit concocts a theory that reimbursement for PCS under North Carolina Medicaid is based on hours of services provided to residents. The United States Department of Justice and the State of North Carolina have declined to intervene in this case, or even investigate the allegations.

Assisted living facilities play an integral part in North Carolina's continuum of care for the State's most elderly and fragile citizens. In North Carolina, 20,000 residents are living in assisted living facilities of which 13,000 are Medicaid beneficiaries. Affinity serves 4,500 residents in the State, 3,000 of whom are Medicaid beneficiaries.

"At Affinity, the most important people in our world are the valued residents who depend on us for their home," said Charles Trefzger, President of Affinity Living Group. "Whether it's offering assistance with activities of daily living or holding the hand of someone who suffers from Alzheimer's, our world revolves around making life better for each member of our communities. The lawsuit is an erroneous interpretation of Medicaid reimbursement law in the State."

One of the primary functions of assisted living facilities is to provide Personal Care Services to residents who need help carrying out activities of daily living, such as bathing, eating and dressing. The PCS program provides funding for low-income individuals who would otherwise be unable to receive care.

Independent assessments are completed shortly after admission to determine the services that a resident requires to live a dignified and independent life. Once determined, a Care Plan is created by the State that directs the care and scope of services to be provided. PCS providers then perform and document the services in accordance with State rules and regulations.

"As North Carolina's largest assisted living provider, Affinity has sustained more than a dozen audits over the past few years by the North Carolina Department of Health and Human Services that upheld our interpretation of regulations and billing guidelines for Medicaid," said Trefzger. "Our top priority has always been providing exemplary care for our 4,500 residents in the State, which is why so many families choose to live in our homes."

Assisted living providers are reimbursed by Medicaid based on the services performed, not the amount of time it takes to provide those services. Therefore, providers can only bill up to the approved amount based upon a resident's independent assessment and Care Plan. Once the provider has billed the pre-determined amount in a given month, the State will not pay any additional amount for that resident.

"It is regrettable that a traditionally underfunded service, one that is critically important to our continuum of care for our elder population, is further challenged financially by lawsuits that move critical dollars from the provision of care to paying lawyers," said Lanier Cansler, former Secretary of the North Carolina Department of Health and Human Services. "It appears the State's guidelines are generally interpreted in a uniform manner across the assisted living industry and the State's Medicaid agency conducts regular audits to ensure compliance.  It's unfortunate that recent legal attacks appear to use meritless interpretations of industry regulations against PCS Service Providers, interpretations that government agencies have not pursued."

The association representing long-term care providers in the State has also indicated that the industry as a whole follows a uniform approach to billing for these services.

"As an industry, we have come to a consensus on the implementation of PCS regulations," said Hugh Campbell, former President of the North Carolina Association of Long Term Care Facilities. "This agreement on implementation is particularly important given the wave of unwarranted lawsuits on long-term care providers in recent years which take away time and resources that should be fully focused on caring for our State's most vulnerable citizens."

SOURCE Affinity Living Group