PROVIDENCE — The McKee administration has determined Rhode Island can retroactively bill Medicaid back to April 1, 2020, for “tens of millions” of federal dollars to help pay the bills of the patients at the state-run Eleanor Slater Hospital, but it cannot do so for care provided more recently.
It’s a complex tale. But it boils down to this: with admissions closed to new medical patients earlier this year as part of then-Gov. Gina Raimondo’s downsizing drive, the state hospital had, by May 1, 2021, morphed into an “Institution for Mental Disease.”
This means: Rhode Island expects to recover millions of federal dollars the state went without between April 1, 2020 and May 1, 2021, amid unfounded concerns that Slater hospital was in violation of a longstanding federal rule barring reimbursement of hospitals where more than 50% of the patients are being treated for mental illness.
But it also means the state hospital, as of May 1, had indeed become an “IMD” where the “primary diagnosis” for 51% or more of the patients is psychiatric. Hospitals with an IMD determination are not able to bill Medicaid for services provided to adults under age 65.
The announcement, by the Rhode Island Executive Office of Health & Human Services, came Wednesday in the wake of a review by a clinical team from Butler Hospital of the patient mix at the state hospital.
“The independent review found, and the EOHHS team concurs, that for the reporting periods April 1, 2020 to May 1, 2021, Eleanor Slater Hospital is not an Institution for Mental Disease (IMD),” according to Rhode Island Medicaid Program Director Benjamin Shaffer.
“This means that the hospital can bill Medicaid for all eligible patients during that time period,” Shaffer said Wednesday.
Going forward, however, Rhode Island has a financial problem.
“Due to the percentage of patients with primary psychiatric diagnoses reaching 51.1% as of the May 1, 2021 reporting period, Eleanor Slater Hospital is currently considered an IMD. No Medicaid billing (for patients age 19 and older and under age 65) will be allowed from May 1, 2021 until the hospital’s IMD mix falls below 51%,” according to the state’s explanation.
“Thus, Medicaid billing cannot resume until the hospital’s census reflects a greater ratio of medical patients, which will not be measured until the next reporting period on December 1, 2021.”
Health & Human Services Secretary Womazetta Jones called the current dilemma a “fixable problem” that dates back to a period when the hospital, as a result of “previous leadership decision-making … was definitely not admitting medical patients.”
Jones said she was unaware this had happened until April, when the previous director of the state hospital agency resigned, she was temporarily put in charge and she “made it very clear that they needed to start admitting medical patients again.”
The Butler team actually found more psychiatric patients than medical patients in every period of time, dating back to April 1, 2020, that was reviewed.
The way the math works, however, there were anywhere from 48 to 60 patients exempt from the count during each review period, because they have intellectual and developmental disabilities, senility or organic brain syndromes that place them outside the so-called IMD-rule. It is not until May 1 that the number of psychiatric patients reaches 51% of the total hospital population (188) at that point:
Now comes decision-time for state officials, including Richard Charest, the director of the state’s Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.
“My team and I look forward to working with Director Charest and Eleanor Slater Hospital staff to further strengthen the hospital’s care of patients, while also reviewing admission criteria, the medical records system, and other processes to make the IMD determination process run more smoothly going forward,” Jones said.
The background: The state suspended billing Medicaid in August 2019 amid concerns the population had evolved to the point that Slater Hospital had morphed into an “Institute for Mental Disease.”
It appeared Rhode Island reached an agreement with the U.S. Centers for Medicare and Medicaid that would allow it to resume billing.
Then came a report by the two top doctors — and the CEO — of the Slater Hospital on the patient mix that raised the same question anew.
The CEO was placed on leave and subsequently left, and the chief medical officer quit, leaving behind a letter in which he portrayed himself as a scapegoat for widespread hospital problems.
In June, the McKee administration hired a clinical team from Butler Hospital, at a potential cost of $60,000, “to conduct an independent review of the facility and medical records of [Eleanor Slater Hospital] patients.
The Butler team came to the same conclusion, though not the same numbers, as the doctors in-house:
“The May 1, 2021 ESH census for qualifying psychiatric patients was 51% of the total patient population.”
The Butler review team included: Dr. Ghulam Mustafa Surti, the chief medical officer for Butler Hospital and senior VP for Care New England; Carolyn Walsh, director of social services and care management for Butler Hospital; Stephanie Rendina, manager of operations for the Department of Social Services and Care Management at Butler.
Going forward, the Butler team recommended the state hospital adopt a basic practice in most hospitals: electronic medical record-keeping.
The Department of Administration, meanwhile, disclosed that the state agency that operates the hospital has hired a consultant to advise on potential re-licensing of the hospital: David Longmoore of Pinnacle Healthcare Solutions, under a $52,000 contract.