When I was working towards my Doctorate in Public Administration, I read about a political concept that is called the Iron Triangle.
In the political arena this concept is used to illuminate the relationship between the legislature, government agencies and interest groups.
How does this concept relate to the field of developmental disabilities? In the field of developmental disabilities, the governmental agency, via regulations and audits, puts pressure on the private provider agency; the private provider agency then puts pressure on the legislature by asking for relief, and the legislature puts pressure on the governmental agency, thus the "triangle" is completed.
I will use this concept to demonstrate what I think can be done in the field of developmental disabilities to equalize pressure that has recently been placed upon private provider agencies.
The governmental funding and/ or regulatory agency enforces the regulations pertaining to the operation of the programs that they oversee and that are operated by a not-for-profit provider agency.
The provider agency must follow the regulations as administered by the governmental agency.
It may negotiate rates but it is more difficult to argue the regulations.
The governmental agency sends out survey teams to determine whether or not the provider agency is meeting its obligations apropos of the regulations.
Programmatic surveys cite deficiencies and usually provide the provider agency with the opportunity to "fix" an area that has been cited.
This is fair.
There is the possibility that, because of a mutual respect and trust, the provider agencies, usually as a group effort, and the governmental agency can arrive at a solution where the regulations are interpreted in a reasonable and fair manner.
Interpretation of the regulations may differ but in the vast majority of cases the regulations are clear.
It has been my experience that for the most part programmatic regulations are written so as to provide the consumer with the optimal in services.
In some instances the governmental agency that sets and enforces the regulations, is the same agency that provides the funding to the provider.
The provider agency is not in a position that encourages disagreement with an entity that both funds and audits.
In recent months the NY State Office of the Medicaid Inspector General, OMIG, has been in their words, "looking for fraud, waste and abuse" in provider agencies receiving Medicaid funds for the services that they deliver.
I have no problems with that mission, in fact I applaud it.
If any agency is fraudulent, or abusive it should not be allowed to be part of the provider network.
If a thorough and in-depth survey shows that Medicaid has been billed in error it is correct that the funds received in error should be returned.
I don't believe that anyone should find fault with that.
But if the mission is to attack fraud, waste and abuse then probably only a micro-segment of the provider agency community would fall under those categories.
Yes, probably most agencies, at one time have billed in error, perhaps using the wrong billing code or possibly being careless.
If the audit shows that the funds were paid to the agency because of the agency's billing error, take the funds back! I have been in the field of DD for over fifty years and I do not personally know one provider agency that has fraudulently billed Medicaid.
There may be inadvertent errors in billing, perhaps, but not fraud.
Webster defines fraud as "an act of deceiving, intentional perversion of the truth, cheat.
" Those words don't describe any provider agency that I am acquainted with.
Abuse is defined by Webster as "a corrupt practice or custom, a deceitful act or deception.
" Again no agency that I have known fits that description.
Arguably, the largest concern with the OMIG audits is the use of a process called extrapolation.
Extrapolation is defined by Webster as "projecting, extending, or expanding known data or experience into an area not known or experienced, so as to arrive at a conjectural knowledge of the unknown area.
" Conjecture is defined as a "conclusion deduced by surmise or guesswork.
" The best opportunity for leveling the "playing field" is the application of the "Iron Triangle" concept.
In the political arena this concept is used to illuminate the relationship between the legislature, government agencies and interest groups.
How does this concept relate to the field of developmental disabilities? In the field of developmental disabilities, the governmental agency, via regulations and audits, puts pressure on the private provider agency; the private provider agency then puts pressure on the legislature by asking for relief, and the legislature puts pressure on the governmental agency, thus the "triangle" is completed.
I will use this concept to demonstrate what I think can be done in the field of developmental disabilities to equalize pressure that has recently been placed upon private provider agencies.
The governmental funding and/ or regulatory agency enforces the regulations pertaining to the operation of the programs that they oversee and that are operated by a not-for-profit provider agency.
The provider agency must follow the regulations as administered by the governmental agency.
It may negotiate rates but it is more difficult to argue the regulations.
The governmental agency sends out survey teams to determine whether or not the provider agency is meeting its obligations apropos of the regulations.
Programmatic surveys cite deficiencies and usually provide the provider agency with the opportunity to "fix" an area that has been cited.
This is fair.
There is the possibility that, because of a mutual respect and trust, the provider agencies, usually as a group effort, and the governmental agency can arrive at a solution where the regulations are interpreted in a reasonable and fair manner.
Interpretation of the regulations may differ but in the vast majority of cases the regulations are clear.
It has been my experience that for the most part programmatic regulations are written so as to provide the consumer with the optimal in services.
In some instances the governmental agency that sets and enforces the regulations, is the same agency that provides the funding to the provider.
The provider agency is not in a position that encourages disagreement with an entity that both funds and audits.
In recent months the NY State Office of the Medicaid Inspector General, OMIG, has been in their words, "looking for fraud, waste and abuse" in provider agencies receiving Medicaid funds for the services that they deliver.
I have no problems with that mission, in fact I applaud it.
If any agency is fraudulent, or abusive it should not be allowed to be part of the provider network.
If a thorough and in-depth survey shows that Medicaid has been billed in error it is correct that the funds received in error should be returned.
I don't believe that anyone should find fault with that.
But if the mission is to attack fraud, waste and abuse then probably only a micro-segment of the provider agency community would fall under those categories.
Yes, probably most agencies, at one time have billed in error, perhaps using the wrong billing code or possibly being careless.
If the audit shows that the funds were paid to the agency because of the agency's billing error, take the funds back! I have been in the field of DD for over fifty years and I do not personally know one provider agency that has fraudulently billed Medicaid.
There may be inadvertent errors in billing, perhaps, but not fraud.
Webster defines fraud as "an act of deceiving, intentional perversion of the truth, cheat.
" Those words don't describe any provider agency that I am acquainted with.
Abuse is defined by Webster as "a corrupt practice or custom, a deceitful act or deception.
" Again no agency that I have known fits that description.
Arguably, the largest concern with the OMIG audits is the use of a process called extrapolation.
Extrapolation is defined by Webster as "projecting, extending, or expanding known data or experience into an area not known or experienced, so as to arrive at a conjectural knowledge of the unknown area.
" Conjecture is defined as a "conclusion deduced by surmise or guesswork.
" The best opportunity for leveling the "playing field" is the application of the "Iron Triangle" concept.
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