Tuesday, May 15, 2012

Why Is My Child's Therapy on Hold?

Time and time again caregivers ask us why their child has to go on hold at the beginning of the month or sometimes in the middle of the month.  When a child is placed on hold for therapy the reasons usually involve a problem with the insurance provider, lack of approval from the patient's physician, or delayed submission of paperwork to get new authorization.  In this blog, we're going to talk about some of the reasons for why patients have to be put on hold and how you as a caregiver may be able to assist us so that we do not have to place your child on hold.
Before we can ever provide therapy services to a patient, we must have doctor's orders stating that the doctor is requesting the patient receive therapy AND authorization from the patient's insurance company stating that the insurance company approves of and will pay for the services being provided.  For our patients who have Medicaid and CHIP, we receive a list from the State on the 1st of every month and this list allows us to verify eligibility for patients with Medicaid or CHIP.  If a patient's name is on this list, it means that the patient’s Medicaid is not active and therefore we cannot treat the patient until the payor source in reinstated.  If the patient switches insurance providers and the plan changes to an HMO plan (Star, CHIP, Molina, CHC, Evercare, or Superior), then the patient will be placed on hold until authorization from the new plan is obtained.  If a patient switches insurance providers and changes to traditional Medicaid, in most cases the patient will not have to go on hold.  This is because traditional Medicaid gives us immediate authorization.  The Medicaid HMO's, on the other hand, can take anywhere from 72 hours up to 2 weeks to give us authorization. 
When it’s time to renew your child’s Medicaid, you get to pick your plan if you are not eligible for traditional Medicaid.   If you do not pick a plan for your child, the state picks one for you. If you get a list of Medicaid HMO's to choose from, please make sure you are choosing one of the HMOS's that MedCare accepts if you want to continue receiving services with us.  MedCare currently accepts Star, Chip, Molina, Superior, Evercare, and Community Health Choice.  We do not accept Amerigroup.  If your child's name does come up on the Medicaid eligibility list and you feel that the state has provided us with the incorrect information, please dial 211 from any phone.  Once you can provide us with proof that your child does in fact have coverage for the month, we can begin treating right away. 
Another reason a patient can be placed on hold is because the Primary Care Physician (PCP) does not sign the patient’s evaluation.  We create a Plan of Care (POC) every 25 weeks and if a patient has traditional Medicaid, the patient will not go on hold when the POC ends because traditional Medicaid gives us authorization for the new POC immediately.  However, if a patient has an HMO plan the doctor will have to sign off on the evaluation before the HMO provider will give us authorization to start the new POC.  For this reason, we usually schedule re-evaluations at least 4 weeks in advance of the end of the POC so that we have plenty of time to get the paperwork to the doctor and signed before the end of the POC.  There are times, though, when this process can be delayed.   If the patient's PCP goes on vacation, it may take longer than usual to get the paperwork signed, which delays us from sending it to the insurance company for approval.  Another example is if a patient goes on vacation or is out sick for a long period of time and misses their re-evaluation.  The longer the re-evaluation is delayed, the bigger the chances are that the patient will have to go on hold.
So how can you as the caregiver help to avoid having your child's therapy placed on hold?  If your child has a Medicaid HMO and you receive paperwork, make sure that you are completing the paperwork and sending it back in before the due date so that the State does not choose a plan for your child.  Each plan is different, so therapy that is covered under one plan may NOT be covered under another.  The less your child changes insurance plans, the better it is for everyone involved!  Also, if you know that your child will be out of therapy for an extended period of time for any reason, make sure you let your therapists and the schedulers know!  That way, the therapists can make arrangements to complete a re-evaluation if needed before it's too late and the child has to go on hold.