AGENCY COULD LOSE MILLIONS; VENTURA COUNTY FAILED TO SUBMIT MEDI-CAL CLAIMS.

Byline: Krystn Shrieve Staff Writer

The Behavioral Health Department could lose $16 million in Medi-Cal reimbursements because it purposely stopped submitting claims once a federal investigation of its billing practices was under way.

State officials say the county department stopped billing for Medi-Cal payments in November 1998 and may only be eligible to receive reimbursements for services provided since March of this year.

``The county has six months from the date of service to submit a claim,'' said state Department of Mental Health spokeswoman Nora Romero. ``There are some triggers, however, that may allow the county to get that money . . . but it has to go through an approval process.''

County Counsel Frank Sieh said officials in the county's Health Care Agency and Chief Administrative Office decided to hold off on submitting Medi-Cal claims to the state because the federal government began questioning the county's Medicare billing.

A letter to the county from the U.S. Health Care Financing Administration, which investigated the Medicare billing, ordered the Behavioral Health Department to hold off on billing Medicare and Medicaid for services rendered between April 1998 and December 1998, during the period of the merger between the Behavioral Health Department and Health Care Agency.

In California, the equivalent of Medicaid is Medi-Cal.

``Our review of the latest materials again demonstrates that your new organization structure is not acceptable for Medicare/Medicaid purposes,'' reads the letter written on Dec. 21, 1998. ``Ventura County should not bill Medicare and Medicaid for services provided by the (Behavioral Health Department) under the reorganization that was put in place in April.''

Romero said, however, that the county could have resumed Medi-Cal billing in March of this year.

``The county called our department in early May and asked if they could resume billing and we said of course they could, and followed that up with a letter later in May,'' Romero said. ``It wasn't until August that they called and asked for technical assistance. We dropped everything and sent a team down there.''

A team of state officials looked over the county's Medi-Cal billing last week. A report on its findings are expected to be released by the state on Friday.

County officials were confident their billing procedures were in order, and the funds would be reimbursed.

``The team told us verbally that our billing is fine,'' Sieh said.

Romero explained that Medi-Cal billing by all counties is filed electronically - usually on a monthly basis. Claims go first to the state Department of Health Services, who will process and approve them. They then forward them to the state Department of Mental Health.

The exceptions for recouping money beyond the six-month period are called ``good-cause reasons'' - such as failure of a patient to present a Medi-Cal card or natural disasters, theft, court decisions or circumstances related to the Medi-Cal certification or recertification of the provider.

State and federal audits and investigations that have been pelting the department since last year's failed merger, have turned up various department blunders which have already cost millions and could cost millions more.

The Board of Supervisors is awaiting final approval from the U.S. Attorney's Office on an offer to pay back $15.3 million in Medicare reimbursements over a five-year period.

In addition, the state also said this month that it is withholding $5.3 million from the Behavioral Health Department's Systems of Care programs until the department shows it is making more of an effort to include members of the community in program improvements.

The county is expected to reorganize its budget in October to reflect the Behavioral Health Department's lack of funding.