Medicaid payments evaporate in NYC

Monday, January 31, 2005

ALBANY, N.Y. - Since New York’s Department of Health closed its medical review office in New York City Nov. 1, rehab suppliers there say that prior authorizations for new wheelchairs and repair work have come to a virtual standstill.

“Not a single downstate dealer has gotten anything approved,” said Laurie Hyams at Total Health Care Industries in New Hyde Park. “It’s all coming back voided, or pended or denied.”

Other suppliers said that by Jan. 7 they’d heard of just two prior authorizations processed since the state transferred all of the NYC medical review work to the Albany office.

The downstate office processed about 17,000 prior authorizations for DMEPOS annually, according to one New York supplier. In September, the Department of Health asked suppliers for suggestions on how to manage the transition, but the suggestions seem to have fallen on deaf ears.

“We knew we were in for a change, but we didn’t realize it would be to this magnitude,” said one supplier.

A spokesman for the Health Department, William Van Slyke, told The New York Times that providers are exaggerating the extent of the problem, though he said he could not supply any figures. “We are seeing a higher number of rejections out of the metropolitan area, but we would dispute that it’s virtually all of the requests,” he said.

“The most common problem is the lack of documentation citing that the product is medically necessary,” he told the Times. “We found that the New York City office deviated from established protocols, and we’re trying to apply the rules and regulations uniformly to every part of the state.”

Suppliers say the Albany office is looking for a level of detail for work that simply should not require as much. For example, the DOH now expects a PT/OT evaluation for certain repair work.

“Let’s say someone’s got a broken power wheelchair?” said one supplier. “What’s an OT/PT going to do after we do our evaluation - back it up or affirm that what we said is wrong.”

Getting OT/PTs to evaluate work is problematic simply because there are too few available, say suppliers, and because the work isn’t remunerative.

Suppliers voiced their concerns at a recent meeting, but Hyams said the meeting didn’t resolve their complaints.

“They simply reviewed the manual,” she said. “It was basically going over how it’s going to be.”