CMS Affirms That Parents Can be Held Financially Liable During Appeals of MCO Funding Denials

The Centers for Medicare and Medicaid Services issued a Proposed Rule (#2390) a few days ago.  The comment period ends on July 27th.  You can read the 8 comments I’ve sent them so far by clicking here.

When you read my comments, you will see that there are some very good things planned in Washington for the States to comply with, and some absolutely dreadful things that the CMS wants to do to Medicaid recipients.  Please read these comments and distribute them to others if you think it would be helpful.

Of particular importance is the plan to make Medicaid recipients “assume financial risk” for filing appeals of “adverse decisions.”  In other words, if a parent appeals an awful decision by a MCO reviewer, and the Administrative Law Judge rules against the parent in a Fair Hearing, the parent would then be obligated to repay the funds spent on delivering treatment to their child during the grievance period.  Seriously.  What parent would consider filing a grievance if they were told that they’d have to pay back the money billed by their service provider for treatment during the appeal process?  Nobody in their right mind, right?  Especially with the incredibly random draw that happens with Administrative Law Judges and how they misread, misinterpret or ignore the law they’re supposed to be upholding.  I have three recent Fair Hearing transcripts that document how perfectly documented evaluations, prescriptions and treatment plans are dismissed by the highest authorities in Pennsylvania’s Medicaid program using the code “failed to meet medical necessary criteria” when that claim is patently and demonstrably false.

I’m writing a screenplay using those hearings as the foundation; the production will be “based on true events.”  Think of “Judgment at Nuremberg” and you’ll get the gist of what I’m working on.

This business of “making the recipients pay if they lose an appeal” will not just have a “chilling” effect on grievance filings, it will freeze them out entirely.

There’s more.  Please have a look at the comments and you’ll see.

Here is a link to the CMS-2390-P proposed rule changes and comments submitted so far.


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