Report: N.Y. mishandles claims

Thursday, August 31, 2006

NEW YORK - Four State Assembly Democrats released a report in July that blasted the Department of Health for mishandling claims for DME, resulting in delays and, in some cases, denials.
The report's findings are no surprise to the DME industry. Ever since the state closed its New York City Medicaid office in October 2004 to centralize operations in Albany, providers have struggled with a prior approval process that's "badly managed" and "rife with inefficiencies," according to the report.
"We've heard it all," said Carol Napierski, executive director of the New York Medical Equipment Providers association.
Providers have done more than hear about it--they've lived it. Things got so bad last year that providers like Landauer Metropolitan and New York Home Health Care Equipment stopped providing custom rehab equipment, which requires prior approval.
At one point, providers were waiting up to a year for the state to process pending claims, according to the report. Previously, the state completed the process within two to three months.
The report charges that the state's reviewers--many of them unqualified--have "overstepped (their) authority by denying certain items deemed medically necessary by physicians and treating practitioners and by proposing alternative plans of care," sending the prior approval process into a tailspin.
Legislators recommend that the state process claims within 21 days and "only overrule the opinions of ordering practitioners based on the opinions of those within the same medical profession." They also recommend the state develop "clear and concise criteria" for prior approvals.
That last recommendation is at the crux of the problem, Napierski said. She's part of a DME Workgroup that was formed last year to streamline the prior approval process--a task that the report points out is "still not done."
"When providers submit a prior approval request, they need to know what's expected," Napierski said. "Right now, there's a lot of back and forth."
Napierski and several providers concede that the prior approval process has improved, but it hasn't improved enough for Alan Landauer, chairman of Landauer Metropolitan, to reconsider providing custom rehab to Medicaid recipients again.
"I'd say we're still happy with our decision," he said.