DIRECTIONS FOR CAREGIVERS DENIED AUTHORIZATIONS FOR DME/SERVICES
Medicaid is a FEDERAL program. Medical Managed Agency (MMA), Health Maintenance Organization (HMO) MUST comply with FEDERAL laws, adhering to legislations cited in medical letters of necessity we’ve provided for you
For example, Mandatory coverage for disabled children below the age of 21
The medicaid allowable ‘fee schedule’ for diapers is 200 per month, as legislation demonstrates, HMO caps at 200 diapers per month but if child requires more than 200 a month due to excessive stooling, urination, on diuretics and INO(S) demonstrate this, it is up to the caregivers to ensure this is properly documented in what’s known as INO’s.
If in a home setting, have a diaper scale, have RNs/LPNS, document how many diapers a day were used and work that into a signed plan of care MD must sign off on every 60 days. (Work with your PDN agency) for accuracy.
*DEMAND ALL COMMUNICATIONS BETWEEN CAREGIVER AND COORDINATOR VIA EMAIL SO CAREGIVER HAS PROOF IN WRITING.
REJECT PHONE CALLS AND PAPER MAIL AS FORMS OF COMMUNICATION.
THIS IS YOUR RIGHT, INSURANCE COMPANIES OFTEN CLAIM THEY MAIL LETTERS OF DENIAL LETTING 30 DAYS LAPSE SO PATIENT IS DENIED DME OR SERVICES.
Caregiver MUST obtain the following: (Jump through hoops)
Layman’s terms:
If given a “No” from your HMO, file a complaint against medicaid provider
In FL, it’s known as Agency for Health Care Administration (AHCA)
In North Carolina: it’s known as North Carolina Department of Health & Human Services
By this stage, you will have a signed letter of medical necessity with cited laws by a G.I (gastronomy doctor) or a medical team, (heart transplant treating physicians for discharge coordinators)
Caregivers MUST keep a copy of these signed letters of medical necessity which must be resigned every 60 days as private HMOs/MMA demand authorizations every 60 days.
Contact the CASE MANAGER from the HMO.
*By FEDERAL law, every case manager who is either a registered nurse or LPN, familiar with what they’re ‘supposed to be covering’ & standard of care legally must aid you in filling out your appeal. By FEDERAL LAW, case managers MUST explain your rights in 4th grade language.
Follow all directions given by the case manager to fill out appeals form. *Demand written answers and email communications from HMO case manager.
Obtain, in writing case managers received faxed and signed by MD(S) letters of medical necessity to the case manager working for an insert MMA
For example, in the state of Florida:
Sunshine, Prestige, Humana, Aetna, or well-care (Well-care has merged with Centene giving the illusion of choice)
Other states, CMS, (Children’s medical services) / (Center for Medicare and Medicaid Services)
Regardless of what’s written in the HMO’s handbooks, legally they MUST adhere to the Federal CMS guidelines in order to obtain medicaid monies from the Federal Government
* Based on FEDERAL CMS guidelines, for any MMA to participate in the Medicaid program for disabled children below 21, despite misleading ‘handbooks’, FEDERAL laws have NEGATED their ‘limitations’ on DME & Services in the ‘advise benefits’ portion. (They trick recipients)
Upon completion of the appeals paperwork case manager will demand, file a complaint against the HMO in your state.
Every state has a “police” for Medicaid/Medicare program. Otherwise known as a ‘regulatory agency’ designed to ensure MMAS are COMPLIANT with CMS guidelines.
You have a right to ask for an expedited appeal. Reasonable timeline clauses differ per state, states have left reasonable timelines ambiguous. However, anything over 45 days is excessive.
Medicaid recipients have a right to ask for life saving treatment authorizations expedited appeals in as little as 24 hours, can be 3 days, or less than 30.
Once paperwork for appeals is submitted, the recipient should be given a date for HMO to render their decision.
More often than not, the HMO is banking on YOUR IGNORANCE.
If denied, after HMO ‘in house appeal’, you will be shuffled to the dreadful ‘fair hearing’ stage.
Since the letters of medical necessity are citing federal legislations, if the appeal is denied by the MMA and the recipient is forced into a fair hearing follow below steps.
A fair hearing date should not take more than 30 days.
If a caregiver is told to go to attend a fair hearing, regardless of state, the above FEDERAL laws are all that’s needed with a signed letter of medical necessity.
By FEDERAL LAW, MMA has 7 days maximum to give caregivers ALL medical records obtained in a zip file. This is the law. If HMO fails to produce this file within those 7 days, legally, the DHH (dept of human health and services) should step in, and fine them due to non compliance insert state’s regulatory agency (in Fl, known as AHCA) employees should be penalized for refusing to forward MMA’s lack of compliance under section 20.555
One tip? If the MMA fails to deliver records within that 7 day time frame? The fair hearing division should rule in your favor based on technicality.
If a state agency designed to protect medicaid/medicare recipients rules AGAINST caregiver, contact the OFFICE OF INSPECTOR GENERAL from the FEDERAL Dept of human health and services.
Ensure you have the signed letters of medical necessity.
Which adjudicator ruled against caregiver
Date & time of the ‘fair hearing’ (I personally recorded the fair hearing using ‘tape a call app’ despite not being admissible in court. From personal experience, AHCA claimed I could obtain the recording of the fair hearing from either AHCA or my HMO. When I requested in writing a copy of this recording dated July 25th, 2019? Both agencies claimed to NOT have a copy of this recording where the medical director committed perjury. Cover your bases.
The medical director + case managers from HMO(s) on the fair hearing conference as they MUST declare themselves.
If the fair hearing is not ruled in caregiver’s favor despite cited federal laws or like in my case, the adjudicator (a clerk at dept of children and families) unfamiliar with legislation or basic anatomy and physiology…
Contact https://tips.oig.hhs.gov/ Office Of Chief general inspector.
The governor of every state appoints a ‘chief general inspector’ who is NOT elected whose job it is to ensure HMOs/MMA are NOT refusing caregivers DME items or services.
File the complaint against their office, to the DHH and demand to speak with the chief general inspector. Take a note of the time and date of the phone call.
For smartphone users there is an app called ‘tape a call’. Caregivers can use this to refer back to later. Email yourselves the information. (Make folders by subject) organize all information in email folders.
If the DHH fails to intervene, contact the department of justice ‘civil rights division’.
https://tips.oig.hhs.gov Option Healthcare fraud Kickbacks Medicaid
Other, then type the name of your insurance company refusing your DME or services
Type in the name of your healthcare company
Fill in the date it happened and follow directions expressing what happened.
Once completed the form, take a screenshot of the complaint number from the DOJ
Immediately contact your senator’s office and file a complaint.
Some have taken to social media and @ ted their senators, reps, governor, DHH, and DOJ with screenshots of unjust denials.
Have a copy of the medical letters of necessity
Every individual you spoke with, time, dates, DOJ complaint ID number. (Screenshot it and email it to yourself)
Request written email communications from your care coordinators (RNS and LPNS) working at insert MMA managing child’s benefits.
Who at insert state regulatory agency caregiver spoke to and the excuses they used for not helping.
The DOJ fines providers (doctors, nursing homes, PDN agencies, DME companies) but never seems to fine HMO(s) for disregarding federal laws economically crushing families of children with disabilities.
Notice of adverse benefits otherwise known as EOB (explanation of benefits)
HMO’s have been given the freedom to draft their own pamphlets of what they will & will not cover by governors, senators and house representatives. Despite this, Federal law negates those pamphlets presented to Medicaid/Medicare recipients when dealing with Mandatory coverage for disabled children below the age of 21.
The result is HMOs are permitted to run rogue with impunity costing taxpayers millions more due to hospitalizations for inadequate care.