Re: Fw: NY Medicaid Responses/A alternate funding source experience !
Tony Barr
Description
Collection
Title:
Re: Fw: NY Medicaid Responses/A alternate funding source experience !
Creator:
Tony Barr
Date:
1/25/2006
Text:
Kim Edgar's recent post(s) hit home.
I highly respect her opinion due to her background of over 10 years of
claims management and supervisory position at a national insurance company.
Her many skills in the insurance industry have given her the knowledge
necessary to manage essential functions within claims and benefit requests.
This includes approval of prior authorization requests, claims payment and
the denied claims appeal process.
Let me share with the listserve subscribers something of interest that we
have found to be a growing trend from several Medicaid states whom the Barr
Foundation deals with on a daily basis.
WE receive on a average of 50 applications per month for funding assistance
for prosthetic rehabilitation from folks and providers that THINK and HAVE
BEEN TOLD they are not eligible for benefits.
Part of our (the Barr Foundation) application requirement for the prosthetic
funding is that a denial letter from the appropiate funding agencies i.e.;
Medicaid/Medicare / Dept.Voc Rehab and other viable sources, be submitted in
writing before we review and consider approval of a application for a
amputee whom THINKS he has no other resources of funding.
We have found that a number of states, particularly in the 40 unregulated
O&P states, the Medicaid/Medicare Depts. whom have previously verbally
denied coverage to beneficiaries and their providers, often times will
reverse that decision when asked to put the denial in writing.
It seems that the Medicaid employee may not want to go on record in
providing the denial in writing since it can be researched and tracked back
to them.
This process not only helps us reserve our funding for those that truly have
no other financial resources, but also puts the patient in the system for
the cost of the initial rehabilitation and subsequent fittings he will be
required to have.
My suggestion to providers and patients, always ask for denials in writing,
the reasons why, and signature of the agency's employee.
Tony Barr
Barr Foundation
www.oandp.com/barr
www.ertlreconstruction.com
-----Original Message-----
From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
Behalf Of Kim Edgar
Sent: Tuesday, January 24, 2006 9:19 PM
To: <Email Address Redacted>
Subject: [OANDP-L] Fw: NY Medicaid Responses
Original Post:
Dear List,
We recently have come across a situation that Medicaid is denying several
items, both prosthetics and orthotic L-codes for frequency issues. I have
checked both our hard copy manual that Medicaid has issued and also on the
EmedNY website and no where are there frequency limitations listed for the
L-codes. NY Medicaid states they are following the NYS frequency
limitations on orthotic and prosthetics. When I question where we can find
that information so we can know if we need to do a prior authorization we
have been told, sorry they are trying to update the website, but there is
nothing in writing. They simply told us we would have to call with every
code every time we had a Medicaid patient. On the codes that we have
already been denied on we now have to do a prior authorization and then
resubmit the claim.
My question is how can they enforce something that we have no access to as
providers? Has anyone else in NY experienced this situation lately? Did
you before the transition? What have you been able to do about it in your
office? Does anyone have any suggestions?
Responses:
Had the same problem with a bilateral BK. Made new legs as he gained weight
(he was 21 years old and the old pros. were 2 yrs. old, he simply matured)
They gave me a hard time, I went back and got prior approval and they still
did not want to pay. Had to finally go to my State Senator to get resolved.
The work was done in May and I finally was paid just before Christmas. A
really sad situation of what our system has become. I am almost ready to
tell Medicaid to take a hike. But getting back to frequency, I was told the
same story that we had to call every time. Talk about a waste of time.
----------------------------------------------------------------------------
-----------------
e have been experiencing this for many months -. Per Computer Sciences,
this was a STATE update and was implemented per the STATE. Per the STATE,
Computer Sciences should have updated us, but we all know that the STATE has
to approve and send out all updates. The transition to the new EMED system
has not helped (there is even talk of the STATE not renewing the contract
with Computer Sciences). We have been communicating & offering samples,
justifications, etc to increase frequency on many of the codes ie: only
allowing 1 joint, only allowing 2 prosthetic socks, etc - many, many, many
of them have been updated and we are finding less and less of the need for
prior approvals - be patient, do the prior auth procedure (they are
approving about 90% of them).
----------------------------------------------------------------------------
-----------------
The home offices of your federal reps and senators should have case managers
that deal with Medicaid and/or small business issues. Medicaid receives
federal funding. Complain to your federal legislators' local offices.
----------------------------------------------------------------------------
-----------------
A few of what I received, but we will be contacting our local reps and see
if they have any insight or suggestions.
Thanks to all for responding,
Kim Edgar,
Office Manager, POA/M&M
I highly respect her opinion due to her background of over 10 years of
claims management and supervisory position at a national insurance company.
Her many skills in the insurance industry have given her the knowledge
necessary to manage essential functions within claims and benefit requests.
This includes approval of prior authorization requests, claims payment and
the denied claims appeal process.
Let me share with the listserve subscribers something of interest that we
have found to be a growing trend from several Medicaid states whom the Barr
Foundation deals with on a daily basis.
WE receive on a average of 50 applications per month for funding assistance
for prosthetic rehabilitation from folks and providers that THINK and HAVE
BEEN TOLD they are not eligible for benefits.
Part of our (the Barr Foundation) application requirement for the prosthetic
funding is that a denial letter from the appropiate funding agencies i.e.;
Medicaid/Medicare / Dept.Voc Rehab and other viable sources, be submitted in
writing before we review and consider approval of a application for a
amputee whom THINKS he has no other resources of funding.
We have found that a number of states, particularly in the 40 unregulated
O&P states, the Medicaid/Medicare Depts. whom have previously verbally
denied coverage to beneficiaries and their providers, often times will
reverse that decision when asked to put the denial in writing.
It seems that the Medicaid employee may not want to go on record in
providing the denial in writing since it can be researched and tracked back
to them.
This process not only helps us reserve our funding for those that truly have
no other financial resources, but also puts the patient in the system for
the cost of the initial rehabilitation and subsequent fittings he will be
required to have.
My suggestion to providers and patients, always ask for denials in writing,
the reasons why, and signature of the agency's employee.
Tony Barr
Barr Foundation
www.oandp.com/barr
www.ertlreconstruction.com
-----Original Message-----
From: Orthotics and Prosthetics List [mailto:<Email Address Redacted>] On
Behalf Of Kim Edgar
Sent: Tuesday, January 24, 2006 9:19 PM
To: <Email Address Redacted>
Subject: [OANDP-L] Fw: NY Medicaid Responses
Original Post:
Dear List,
We recently have come across a situation that Medicaid is denying several
items, both prosthetics and orthotic L-codes for frequency issues. I have
checked both our hard copy manual that Medicaid has issued and also on the
EmedNY website and no where are there frequency limitations listed for the
L-codes. NY Medicaid states they are following the NYS frequency
limitations on orthotic and prosthetics. When I question where we can find
that information so we can know if we need to do a prior authorization we
have been told, sorry they are trying to update the website, but there is
nothing in writing. They simply told us we would have to call with every
code every time we had a Medicaid patient. On the codes that we have
already been denied on we now have to do a prior authorization and then
resubmit the claim.
My question is how can they enforce something that we have no access to as
providers? Has anyone else in NY experienced this situation lately? Did
you before the transition? What have you been able to do about it in your
office? Does anyone have any suggestions?
Responses:
Had the same problem with a bilateral BK. Made new legs as he gained weight
(he was 21 years old and the old pros. were 2 yrs. old, he simply matured)
They gave me a hard time, I went back and got prior approval and they still
did not want to pay. Had to finally go to my State Senator to get resolved.
The work was done in May and I finally was paid just before Christmas. A
really sad situation of what our system has become. I am almost ready to
tell Medicaid to take a hike. But getting back to frequency, I was told the
same story that we had to call every time. Talk about a waste of time.
----------------------------------------------------------------------------
-----------------
e have been experiencing this for many months -. Per Computer Sciences,
this was a STATE update and was implemented per the STATE. Per the STATE,
Computer Sciences should have updated us, but we all know that the STATE has
to approve and send out all updates. The transition to the new EMED system
has not helped (there is even talk of the STATE not renewing the contract
with Computer Sciences). We have been communicating & offering samples,
justifications, etc to increase frequency on many of the codes ie: only
allowing 1 joint, only allowing 2 prosthetic socks, etc - many, many, many
of them have been updated and we are finding less and less of the need for
prior approvals - be patient, do the prior auth procedure (they are
approving about 90% of them).
----------------------------------------------------------------------------
-----------------
The home offices of your federal reps and senators should have case managers
that deal with Medicaid and/or small business issues. Medicaid receives
federal funding. Complain to your federal legislators' local offices.
----------------------------------------------------------------------------
-----------------
A few of what I received, but we will be contacting our local reps and see
if they have any insight or suggestions.
Thanks to all for responding,
Kim Edgar,
Office Manager, POA/M&M
Citation
Tony Barr, “Re: Fw: NY Medicaid Responses/A alternate funding source experience !,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/225983.
