Caught in the Middle

For parents of children with special health care needs, there little more frustrating than attempting to sift through the byzantine codes that determine who is supposed to pay for their child’s care. Securing prior authorization of medical services from MA proves to be a vexing challenge. Many parents stories sound the same: “MA refused to cover my child’s speech therapy because they said her condition was being treated at school.” Or, “Therapies for autism are impossible to secure under MA.” Or even, “They barely even looked at my file when they reviewed my case.” These were some of the sentiments voiced at the FMAP legislative listening session with State Rep. Mark Miller (D-Monona). The session drew some 50 parents, advocates, caseworkers and a group from the state legislative audit bureau, which is performing an audit of the MA prior authorization process.

Miller told the group that “there is a recognition on both sides of the aisle that there are problems with MA that are going to require a legislative solution.” From a policy perspective, Miller lamented the “significant resources for the treatment of children with special health care needs” that are “wasted in arguments over who pays for what.” The unfortunate result, “is that parents get caught in the middle of these arguments,” says Bobby Peterson, Executive Director of ABC for Health.

The arguments are primarily over MA prior authorization for medical services. Most problems arise when MA does not deem a specialized treatment, such as protein-free food, or a device like a touch-talker, medically necessary. Alternatively, MA may claim that the treatment is covered under a child’s individualized education plan (IEP). IEPs are drafted by a child’s parents, doctor, and school therapist and are meant to serve as a record and map for development, services that are “education related” (as opposed to “medically related”) are covered under an IEP. However the line of necessity between educational and medical care is incredibly fuzzy, but Medicaid managed care organizations will at times use that distinction to deny care.

“Third party payers are overzealous in the interest of cost containment,” says Peterson. “The child is no longer the focus, the system is the focus.” ABC attorney Ray Laravuso echoes these sentiments. “It can be hard to get them to understand that many of these services are medically necessary and that they should be covered by MA,” says Laravuso.

There were several issues raised during the session, but all are rooted in the constant battles over who should pay for services. These conflicts are exacerbated by the fact that prior authorization approvals are slow, as is the appeals process. The process is exhausting for families and providers, and unfortunately the different staff persons inside the Medical Assistance program provide conflicting information—or no information at all. Add to this the fact that civil legal representation is not readily available for families in Wisconsin, and the problems with the process can seem nearly intractable. There are solutions though, and many of them were offered by the parents at the session. Among them:

• Require that the insurance company, parent, school district and MA representative meet when there is a funding dispute. This would make it easier to agree on who would provide what services.
• Clarify the funding streams for necessary services. This would be a relatively simple legislative solution and could clearly determine with whom the responsibility for payment lies.
• Create training for physicians and therapists regarding how to write an effective prior authorization. This would address both the issue of fatigue and hopefully speed up the process by teaching care providers how to secure prior authorization.

Representative Miller was receptive to this feedback and expressed optimism that these issues could be resolved in the coming legislative session. The fact Miller is a Democrat and the audit of the prior authorization process was brought by two Republicans inspires hope that he is right. To contact your legislators about this issue, visit www.legis.state.wi.us/waml or call 608.266.9960.

School Based Occupational and Physical Therapies

• The provision of school-based therapy is governed by federal and state laws. Therapy is a related service to special education and is provided only if the child needs therapy to function in the educational setting.
• In the school, the Individualized Education Program (IEP) team determines the need for therapy. Parents, physicians and school therapists are part of this team. The team determines the amount, frequency, and duration of therapy – not just the physician alone.
• Therapy may be provided individually or in small groups by a therapist or therapist assistant. Intervention may or may not be provided directly with the child. Collaborating with educational staff to modify the child’s environment and daily school activities is always part of school therapy.
• Therapy takes place where the child receives education. Appropriate intervention may be provided in classrooms, hallways, gyms, playgrounds, lunchrooms, bathrooms, or in a separate therapy room. Medical treatment is not provided.
• The decision to discontinue therapy is made by the IEP team. This may occur when the student no longer is eligible for special education, when other members of the IEP team can provide necessary interventions, or when the child can perform school tasks without therapeutic intervention. There may still be a need for community services.

Community Based Occupational and Physical Therapies

• Community-based therapy is governed by state and national practice guidelines that focus on a child’s medical/functional needs in home and community settings. It is provided in clinics, hospitals, homes and community settings.
• In community-based therapy, the physician, family and therapist make the decision regarding amount, frequency and duration of therapy recommended. The amount of therapy actually received may be affected by whether or not an insurance company, Medicaid Program or other funding sources reimburse for the recommended services. Denials of payment are often based on a perceived duplication of service between community and school providers.
• In community-based therapy, the physician, family and therapist make the decision regarding amount, frequency and duration of therapy recommended. The amount of therapy actually received may be affected by whether or not an insurance company, Medicaid Program or other funding sources reimburse for the recommended services. Denials of payment are often based on a perceived duplication of service between community and school providers.
• A therapist or therapist assistant typically provides individual treatment. Individualized home programs and ongoing caregiver training are necessary parts of the service to encourage carryover of treatment. Families have the opportunity to seek out services from a therapist with specialty training in areas such as soft tissue mobilization, post surgical intervention, sensory integration, aquatic therapy or neurodevelopemental treatment.
• Therapy takes place where the child receives education. Appropriate intervention may be provided in classrooms, hallways, gyms, playgrounds, lunchrooms, bathrooms, or in a separate therapy room. Medical treatment is not provided.

Dane County

ABC for Health recently hired Barbara Katz to serve as the agency’s Parent Consultant in Dane County. Working in the area of agency outreach, Barbara will be responsible for working with parents and parent groups throughout Dane County to identify issues and problems that families are facing when working within the managed health care system. As part of this community wide outreach, Barbara will also work to increase awareness of the direct client services ABC offers to families that have children with special health care needs who are currently experiencing problems with their health care.

Barbara is the mother of three boys, ranging between the ages of 7 and 12. Her middle son has significant development disabilities and has been the inspiration for her work in this field. Trained professionally as a nonprofit agency administrator, Barbara also serves as a volunteer in leadership positions with several disability-related programs in Madison.

If you are interested in working with Barbara in her outreach efforts, or would like more information about these initiatives, please contact her at ABC for Health in Madison at 608.261.6939 x214 or through email at barbk@safetyweb.org.

Chippewa County

In their work with families, Rose Marsh and the Chippewa County Families MAP project have been looking at supplemental security income (SSI) eligibility and how people can avoid denials. More and more clients are coming to Marshfield with mental health problems and scant insurance coverage. And many are turning to SSI, but all too often they are denied.

One step that Marsh has taken is bringing in speakers such as Mary Kay Peterson from the Social Security Administration. The speakers educate caseworkers on the requirements for SSI, including how to accurately fill out the necessary paperwork. In an attempt to broaden these educational opportunities, Marsh has arranged for Jim Twist from the state Disability Bureau to make a presentation on SSI eligibility issues to the next HealthWatch meeting.

Milwaukee County

Despite being the most populated county in Wisconsin, the Milwaukee County pilot program’s main focus has been outreach. The problem in this area is not lack of advocacy for children with special health care needs, but lack of knowledge among families of all resources available to them. In this context, referrals between agencies are few and far between.

Patricia Erving at Community Advocates has been working on outreach for the Families MAP project with agencies around the Milwaukee area. In addition, she has created a brochure for families outlining what services are available to them; such as case management and advocacy for their child’s health care needs; as well as what they can do to participate in the project.

In addition to outreach efforts, the Milwaukee pilot has committed to staff education by having several speakers address staff on the prior authorization process since the beginning of fall. One speaker, Barbara Evans from the Department of Health Care Financing, said that clerical errors are the reason behind 70% of prior authorization denials. This has led staff to refocus on the details of the application process.

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