Wednesday, December 22, 2010

Hawaii Medicaid joins in Evercare's "Blame the Victim" game

Back on November 29, I published a story about a threatening letter I had received from the head of Unitedhealth Group's Hawaii operation.  In my response I had pointed out that I had been following all their procedures, it was Unitedhealth that was violating them, and in so doing, harming my daughter Hannah.

On December 6, Ken Fink, Hawaii State Medicaid Director sent me his own version of the UnitedHealth letter.  Fink, whose salary is rumored to be more than twice the $113,000 received by his predecessor, again makes it sound as if the victim is to blame.

I responded to Fink's letter on December 6. Here is the text of my letter:

This email is in response to your letter dated December 6, 2010 (attached) which was received by me on December 8, 2010.

The issue is:
When a prior authorization by my daughter's physician/provider is submitted which follows all prescribed Evercare protocols, Evercare has failed to give me proper written documentation regarding the possible denials which would include information of any adverse action and my rights to appeal, thereby violating Federal law.

According to the email I received from ... CMS, DHS MQD was going to research and resolve the issue, not simply re-state Evercare's response to me. Can someone please follow Federal law and state contract and please help me and my child? Will someone please step up? I am giving you all the academic reasons as well as the Federal laws which Evercare is violating along with the statues the State is violating for lack of oversight of the MCO (Evercare).  As a mother and caregiver of a totally dependent disabled child, all I am asking is that Evercare follows the law and do their job for which Evercare receives high compensation (tax payors money).

Your letter addresses old issues and regurgitates David Heywoods' (Evercare) prior letter in content; these issues are moot as all of us (me as her mom, the therapists and doctors) followed the required processes in filling out the Prior Authorization request forms and correctly submitted the needed documentation to support the requests.

What I am claiming is the stated issue and Evercare's continuous violation in which DHS-MEDQUEST has already cited Evercare which resulted in the corrective action plan for complaints, grievances, and appeals (in which sanctions were imposed). Evercare is not following BBA requirements regarding Complaints/Grievances/ and Appeals processes.

Evercare is claiming that the member's family or MD/provider is not following required Evercare processes. This is not a true statement and is not the issue. Evercare never brought this up during all the months since the request for prior authorization was submitted in May 2010, and in fact, they contradict themselves when they verbally admitted to receiving the request and approved less than what prescribed. So the prior authorization was successfully submitted by Hannah's physician to Evercare.
I am claiming that when a proper prior authorization (PA) for services is submitted to Evercare, a phone call (nothing in writing) is communicated to the provider that the requested services are denied (not approved) and/or that a lesser amount of service is approved (deviates from theprescription). NOTHING IS PUT INTO WRITING TO NOTIFY ME OR HANNAH'S PROVIDER OF THE ADVERSE ACTION and to inform me of our rights to appeal.

How it should work is that when my daughter's physician/provider submits the documentation required for the request of service/ medication/DME and the health plan denies and/or deviates from the request (less than what is requested) it goes into a complaints, grievance, and appeal mode as required and by failing to follow this process, the health plan is in direct violation of Federal statute, B.B.A. sections.
438.424: Grievance System
. 438.400: Statutory basis and definitions;
. 438.402: General requirements;
. 438.404: Notice of action (including timeframes of notice as
contained in Sections: 438.210(d)(1); 431.211; 431.213; 431.214);
. 438.406: Handling of grievances and appeals;
. 438.408: Resolution and notification: Grievances and appeals;
. 438.410: Expedited resolution of appeals
. 438.414: Information about the grievance system to providers and
subcontractors (important related to high number of non-participating
providers who do not have formal contracts with Evercare--therefore no
requirement to meet Federal BBA requirements/ no quality oversight from
MQD/CMS or EQRO under BBA 438. Subpart E)
. 438.416: Record-keeping and reporting requirements
. 438.420: Continuation of benefits while the MCO or PIHP appeal and
the State fair hearing are pending
. 438.424: Effectuation of reversed appeal resolutions
As further consequences of direct violation of the C/G/A processes

The current situation is in regards to a PA [Prior Authorization request form] that was successfully submitted [in May 2010] ... This [lack of any written notice] constitutes an adverse action by BBA definitions as well as violations regarding lack of written notice with appeal rights, specifically BBA reg Subpart F, and member's rights violations: Subpart C.

I am cc'ing CMS on this matter as there is still no process for Complaints, Grievances, and Appeals and I am following the processes as set forth by the BBA. I am following the PA processes of Evercare, but Evercare is not documenting in writing the denial of my prescribed services, medications, DME (nothing in writing setting forth the denial or cuts in services) and nothing is in writing by Evercare setting forth our rights to appeal their decision.

In my opinion, Evercare's letter is considered retaliatory and your response and lack of oversight of Evercare has caused continuous harm to my daughter. In fact, in the first visit by Evercare and their attorney to my home on Kauai, Evercare's attorney made it very clear that Evercare needed to put all denials and cuts in services and supplies in writing to me and give me my rights to appeal (process).  These instructions are not happening and therefore, Evercare's failure is a clear violation of Federal law. In fact, it was agreed at that meeting that all communications in the future, even with Hannah's field supervisor, would be in writing.

I want to reiterate that these Federal laws (BBA 432) and mandated oversight of these MCOs is intended to provide required mechanisms to protect patient rights and to insure that problems are tracked, trended and resolved in a nationally accepted mode of quality standards. If there are trends identified related to continuous violations, then a corrective action is taken to ensure that no member is hurt, especially the aged, blind, and disabled; hence the purpose of the law. With documentation, there would be a mechanism to insure that no harm comes to the client and that added anxiety to the member and family and caregivers is decreased.

Again the issue is:
Even though a prior authorization has been submitted by my daughter's physician/provider which follows all of Evercare's prescribed protocols for submitting a PA properly, Evercare has twice (again) failed to give me proper documentation regarding the denials or informing me of any adverse action in writing with my rights to appeal, thereby violating Federal laws (BBA).

As of today, there have still been no official Notices of Action sent out by UnitedHealth for the items brought to the attention of the head of Hawaii's Medicaid program almost two weeks ago.

It makes me wonder, if Hawaii Medicaid is so cavalier about Evercare's constant violations of federal regulations, what else are they standing back and ignoring?  The thirty-six percent increase in the death rate of our local aged and disabled population?  Threats to tear severely disabled children away from their families and throw them into institutions if the families don't back down on their requests for services?

Over 41,000 of our state's most vulnerable citizens, our elderly and children as well as adults with disabilities, are enrolled with UnitedHealth and Wellcare.  The state pays the two companies over $100 million every month without keeping track of how much of it is actually spent on medical services.

Governor Abercrombie announced the state has a $410 million shortfall for fiscal year 2012.  It seems to me that turning our Medicaid system back into one that only pays for actual services delivered could knock what, twenty percent, off that total?  Then the state could hire back the three-hundred odd people at DHS whose jobs were transferred to employees of UnitedHealth and Wellcare.  Then our federal funding could actually to to helping the people of Hawaii, rather than just lining the pockets of two out-of-state for-profit corporations.

Tuesday, December 7, 2010

Hollyrod's fundraising campaign to give away iPads to people on the autism spectrum is a great idea

I reprinted a press release over on the CDREA news page, that the Hollyrod Foundation is taking applications to give away iPads to qualifying individuals on the autism spectrum.

The other side of this is the fundraising campaign to pay for the hardware as well as the special applications that will be needed.

The more money the Hollyrod Foundation can raise, the more iPads they will be able to give away.

My daughter Hannah has just started with using a Dynavox, but I got her an iPad to see what else it could add to her learning experience.  I have been absolutely amazed at the variety of games, stories, puzzles, and other activities that are available for children like Hannah.  If you've never met a child who is physically incapable of communicating with you verbally, it can be hard to imagine the pure joy they get on their faces when they start to "get it". 

This is a great idea, and I hope it catches on.  From the standpoint of a mom, I don't think there's ever been a greater gift I could give my daughter than the ability to communicate with us.

According to the Hollyrod Foundation's website,

Inspired by a father and son, actress, author, philanthropist and co-host of "The Talk", Holly Robinson Peete and retired NFL quarterback, Rodney Peete founded the HollyRod Foundation in 1997. The HollyRod Foundation provides medical, physical and emotional support for those living with Parkinson's Disease and Autism.

Monday, December 6, 2010

Hawaii DD Division apparently admits to defrauding federal government and state taxpayers

According to a November 16 letter from the Hawaii Department of Health's Developmental Disabilities Division, the program has apparently been caught by federal authorities defrauding Medicaid.  The DD division established new reporting guidelines that went into effect on December 1, and the letter emphatically tells recipients to comply with ongoing federal and state audits.

The news was quietly inserted into a letter that went out to DD waiver participants and providers with a headline of "documentation requirements" that was a bit misleading.

The Fray letter states "as a result of the recent Payment Error Rate Measurement audit conducted by CMS, the Med-QUEST Division is implementing new documentation requirements for PAB services."

Last April I reported that CMS was unable to deny rumors that Hawaii's Payment Error Rate Measurement could be as high as fifty percent (it's legally supposed to be between three and five percent).  

(paraphrased from then)  What would a 50% Medicaid payment error rate mean?  It could mean that half of all Medicaid claims are paid twice:  once by either Evercare or Ohana through their capitation payments, and the second time by Medicaid's fee for service program.

Here is how it might happen:

1.  ACS, as the fiscal agent for Hawaii's fee-for-service Medicaid program, charges a fee for every claim they submit.

2.  Hawaii receives matching funds from the federal government to pay these fees for ACS's services, just as they do for the state's aged and disabled program operated by Evercare and Ohana.

3.  ACS could be billing the state for claims incurred by patients served by Evercare and Ohana.

4.  ACS would then be receiving federal (and state) funds for claims that are the responsibility of Evercare and Ohana and which are included in the calculations for the monthly per person payments (capitation payment) they receive.  Evercare (UnitedHealth) and Ohana (Wellcare) are retaining their full capitation payments, hence the double payments.

What that means for Hawaii is that suddenly our Medicaid budget could be half of what it should be.  For example, since the state's total Medicaid budget for FY2010 is about $1.4 billion, then suddenly the state might have only $700 million to spend.

Out of that comes the fifteen-to-twenty percent net operating profit UnitedHealth and Wellcare skim off the top of their state capitation fee payments.  That's at least another $92,000,000. 

So from the original annual budget of about $1.4 billion,  only about $608 million is left to spend on actual services for Hawaii's Medicaid population.

When services are cut, the Medicaid profits aren't cut, and the capitation fees not only are not reduced, at least here in Hawaii they've been increased several times by means of "contract amendments".    The Medicaid company cries poor and that it is a victim of rising medical costs, to justify increases in the capitation fees paid by the states.

This is why Hawaii's Medicaid waiver program for our aged and disabled population experienced a thirty-six percent increase in the death rate of participants within its first year of operation.

Friday, December 3, 2010

NPR series starts today on "the new civil right" for people with disabilities

 Copied from an email forwarded to a group I belong to:

NPR will run stories that look at the new civil right, after the Olmstead decision, to get care at home.

The first story-about that right--runs today, Thursday, December 2nd (4:30 and 6:30 Eastern time) on All Things Considered on your NPR station. (Or you can find it by going to . You can listen to the radio story there. Also at our Web site, you'll find additional stories, a data base of every nursing home in America and the levels of independence in each one, a map t hat shows how much each state spends of its long-term care dollars on home and community based care, photos, and a chance for you to comment on the stories.

A second story runs tomorrow, looking at federal enforcement since the Olmstead decision. Also on All Things Considered, probably at the same time.

Next week, two more stories will run. The first-which has just been moved from Monday to Thursday-will run on Morning Edition, December 9th. It looks at the surprising group that is a growing percentage of the nursing home population: 31 to 64 year olds. This is built around the story of Michelle Fridley, at an ADAPT action in Washington in the spring.

That night on All Things Considered, we'll run a story on the Children's Freedom Initiative, an attempt to find alternatives to nursing homes for young people with disabilities.


About Me

My photo
I'm the mom of a child with disabilities. Hannah's first neurologist said she might never develop beyond the level of a 2 month old infant, and there wasn't anything I could do about it. The brain damage was just too severe. Nine years later, she walks, uses a touchscreen computer and I've just been shown she can learn to construct sentences and do simple math with the right piece of technology. Along the way, I discovered I needed to teach myself what Hannah's rights to services really were. Learning about early intervention services led to reading about IDEA and then to EPSDT. I've been waiting for the Obama administration to realize the power and potential of EPSDT for the medical rights - including the right to stay at home with their families - of children with disabilities. The health reform people talk about long term care, and the disability people talk about education and employment, but nobody is talking about EPSDT. So I am.