Tuesday, April 19, 2011

What a Medicaid audit taught me about writing.

Medicaid has two functions. One is to provide needed medical services to people who can't afford healthcare. The other is to keep unscrupulous opportunists from profiteering off what's actually a pretty limited pool of funds. (Because in North Carolina healthcare is privatized and the folks providing the care are for-profit corporations who need a positive cash flow if they're going to pay their bills and feed their families.)

Mental health is probably the most difficult field for Medicaid to monitor. Schizophrenia is not like a broken fibula – you can't take before and after x-rays to see how well it's healed. There's no blood test for Post Traumatic Stress Disorder; almost all diagnoses depend on subjective – trained and disciplined, but still subjective – interpretations of assessments, family histories, and direct observation. There's a reason this is called a soft science.

Since we can't produce pounds of recovery or inches of stability for objective measure, we have to document everything we're doing. This documentation goes through two sorts of review. Medically, every sixty days licensed clinicians review treatment reports and, if the intervention seems efficacious, authorize another two months of service. Financially, at random intervals – usually with a few weeks' notice –Medicaid auditors pull 10% of an agency's files and go through to confirm the dot over every "i" is precisely centered and every "t" crossed at exactly 90 degrees. Does the Comprehensive Clinical Assessment designate the services being provided? Are the signatures dated in the correct order documenting required sequence in developing the Person Centered Profile? Do all signatures include proper credentials? (Case in point: I am what is known in the industry as a Q. If you think of the mental health system as office computers sharing peripherals, I'm a hub; I don't actually do anything, I just help the parts that do do things talk to each other. A few years ago my official designation changed from "Qualified Mental Health Professional" to "Qualified Professional." If I had followed my signature with "QMHP" instead of "QP" at any time since the change the report or treatment plan would be invalid and my agency would have to pay back any monies received for providing services connected to that document.) Sounds rough – sounds ridiculous, in fact – but remember it took tax accountants to bring down Al Capone. Any fraud or mismanagement is going to show up in the paperwork.

I am a very personal-interaction kinda guy. Unconditional positive regard is my default mode and I'm always interested in finding out how others see the world. For those of you into personality shape classification, I'm a squiggly line. I don't just think outside the box, I sometimes have trouble finding the box. Anyone who's worked with me will tell you I'm good at mental health and absolutely horrid at paperwork. So you can imagine my delight, and the joy of my employers, when word came down a few of my files were being yanked for a Medicaid audit.

For two weeks I went through those files making sure everything was in order. Checking dates and signatures and releases and authorizations – all of the pieces of paper that seem unrelated to helping anyone but which are vital to making sure the people I serve receive the services they need. Everything was there, I do my job, but my stuff-everything-in-the-jacket filing method meant the folders had to be put in order, everything set where it should be for quick reference and easy access. By the time the auditors descended I had taut and shiny files ready for the closest inspection.

As I considered my files – the orderly and freshly polished binders ready to show off everything we'd done and why to best advantage and the equally complete but scruffy expansion folders jammed with randomly arranged forms and correspondence – I thought about writing.

Remember when you were learning the basics of writing, the rules and procedures, and you could think of a dozen famous woks that did not follow those rules? If you ever cited those examples you might have been told that when you knew the rules well enough you'd know when you could break them. I can't speak for you, but I know that from that moment on I looked forward to the day I could break the rules and get away with it. And once I got away with it - the first time I broke some rules and the story sold and my work was praised for being original and unexpected - there was no looking back. I was a writer, original and unexpected; I made my own rules.
Every example of broken rules in great fiction stands out because of the contrast. That moment is memorable because it is surrounded by solid, workmanlike prose that set up the moment and carried the reader to that point. There's no reason not to strive for the unusual, the different, the original way to tell your story. In fact, you should be doing that every time you stare down the blank page. But remember that extraordinary buildings are created through thoughtful use of ordinary stones. Sticking to the basics of writing – putting things where your reader can find them easily, setting events in the order she expects – may feel like you're riding with training wheels, but do it. And don't do it like it's something you have to do, some dues you have to pay, to get to your story. Focus on what you're doing and put in the time and effort to get the basics right.
Because without a firm foundation of comfortable, reliable basics, your moments of transcendence will fail.


Charles Gramlich said...

Goes to show how far a writer will go for a workable metaphor. :) I think it works here very well though. I like this.

Liane Spicer said...

In total agreement, KeVin. Breaking the rules as a result of laziness, ignorance or gimmickry can never be effective.

I empathize with your Medicaid experience more than you think. I was privileged (or otherwise) to witness firsthand the lead up to and fallout from a Medicare/Medicaid audit at a friend's home health agency in Florida. Whereas you often can't find the box, my friend refused to even acknowledge its existence. Throw the results of his bizarre modus operandi (I discovered in due course that 'bizarre' was the norm in SF) into the ring with stony-faced agents of the government examining files with microscopes and the results were, um, interesting. So interesting, in fact, that my second novel is set - where else? In a home health agency in South Florida at the height of an AHCA audit.