When it comes to Medicaid providers in the State of New Mexico, providers looking for relief from auditors looking to recoup dollars can count on no help from the state. This is due to a recent bill that Republican Governor Susana Martinez declined to sign into law that would provide some relief.
The beginnings of this bill can be found in June of 2013, when the New Mexico Human Services Department suspended Medicaid payments to 15 behavioral health providers throughout the state. This was based on what the department labeled, at the time, as a “credible allegation of fraud” as discovered by an audit conducted by Public Consulting Group (PCG). In all, the state reported that it found roughly $36 million in overbilling in total from the 15 providers in question.
Approximately one month later, eight of the suspended agencies filed an unsuccessful suit in U. S. District Court to have payments reinitiated, but failed. This led to the shuttering of some of the agencies that had their payments suspended.
Over the next two years, all of the agencies were eventually cleared of wrongdoing, with the few providers whose doors remained open being reinstated, although subsequent state audits did find evidence of some overbilling.
Based on the detrimental effects of the original payment suspension, and the continuing struggles of New Mexico to provide services to behavioral health patients, New Mexico Senate Pro Tempore Mary Kay Papen sponsored a bill that would have given an opportunity for providers the opportunity to review allegations of fraud brought against them, along with the right to respond to allegations either via administrative hearings and in district court.
Governor Martinez had until the close of business this past Friday, April 7th, 2017 to sign the legislation and make it law. She did not sign, meaning that the current lack of rights suffered by providers against which an allegation of fraud is made remains the status quo.
In order to properly assess the detrimental effects of the original payment suspensions to the behavioral health system in the “Land of Enchantment,” it helps to look at the present landscape of behavioral health care.
In order to make up for the sudden shortfall of behavioral health providers in the state caused by the original suspension, five firms from the neighboring state of Arizona were brought in to service the needs of approximately 30,000 patients. Due to an economic downturn in the state, deep cuts in Medicaid payments have taken hold in the interim four years. This caused four of these firms to leave the state. To complicate matters, the handful of providers who survived the original payment suspension and kept their doors open have become gun-shy and are not only no longer seeing Medicaid patients in the state, but have no plans to seek credentials to see Medicaid patients in the future.
While the state reports that access to behavioral health services has increased by 75 percent over the past two years, lawmakers in the state have disputed that number, citing the new financial constraints as a barrier to care.
The state is now almost four years into a saga that has left its behavioral health system in shambles, all because of an overstated, overzealous audit. Without the governor’s signature on this important piece of legislation, providers have lost trust in the state’s Medicaid system as an adequate funding mechanism for the provision of services.
Auditing agencies reviewing services are still not making a clear distinction between fraudulent activities and administrative errors. When this is combined with the lack of due process rights for providers in the state, along with suddenly low reimbursement for services, the ongoing health and welfare of patients across the state is now jeopardized.
New Mexico now stands as proof of the consequences of not allowing providers adequate rights to address allegations of payment irregularities.
As the Centers for Medicare & Medicaid Services (CMS) clarifies existing Medicare policies like the Two-Midnight Rule, which guides the appropriateness of inpatient services, some
Today we’re talking about a major shift in Medicare rules that’s going to impact hospitals, surgeons, and physician advisors alike: the phasing out of the
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
