Medicaid no PAL to providers someproviders

Wednesday, January 31, 2007

BATON ROUGE, La. - Louisiana Medicaid recently added another layer to its prior authorization process for power mobility devices, and, as a result, denials have jumped for some providers.
Jim Glaes, a CRTS with Southern Rehab Home Medical in Metairie, Ga., who's been in the business 25 years, has seen his denial rate balloon from about 5% to 30% over the past few months.
"A year later, we've finally come back from hurricanes (Katrina and Rita), but now Louisiana Medicaid is driving us nuts," he said.
In addition to a supervisor and nurses, the state's Medicaid program now employs prior authorization liaisons or, ironically, PALs. The PALs act as gatekeepers, approving and denying requests.
Making a bad situation worse, there doesn't always appear to be any rhyme or reason for the denials, providers say.
"We recently submitted a prior authorization for four new tires," Glaes said. "They wanted to know why the wheelchair needed new tires. We told them the old tires were worn out. They denied the request, saying they wanted to know how badly the tires were worn out."
Providers have begun to wonder whether they're seeing an up tick in denials due to the lack of qualifications of the state's PALs.
"You have to have a PT or OT participate in the evaluation for a wheelchair, but (Medicaid) has a nurse or someone with fewer qualifications reviewing the request," said one provider. "You'd think the state would want someone on the same wavelength reviewing the claims."
Thanks to their PALs, rehab providers have had to spend more of their time appealing denied requests, and their patients have had to wait longer to get their equipment, providers say.
Some providers report their denial rates have remained consistent at about 10%.