The Department of Community Health (Medicaid) has made changes in the Children's Intervention Program (CIS) that will negatively impact children receiving therapy services in Georgia.We encourage you to get involved and voice your concerns to those who can make a difference.
On behalf of occupational, physical, and speech therapy providers in Georgia we want to bring your immediate attention to the grave ramifications regarding Medicaid changes on early intervention services in Georgia. These changes were implemented in the Children’s Intervention Services (CIS) program beginning June 1, 2006 in the North, Metro and Central regions of Georgia and will be implemented in the remaining areas September 1, 2006. This impact statement is to draw attention to the fact that if the present changes remain in effect, the children with disabilities will be deprived of needed services and the lack of these services will ultimately cause the State of Georgia much more in medical costs over the long term. Outlined below are critical issues that require immediate attention and action.
First and foremost is the issue of significant increase in paperwork and bureaucratic red tape. The Care Management Organizations (CMOs) process for prior approval (PA) for therapy to children is very inefficient and imposes an undue burden on the therapists providing valuable services. Issues include: requirements for numerous and redundant forms; repeated requests for paperwork rework and requirements to re-file; computer systems that are often “down” during critical billing periods; lack of timely response from the CMOs to resolve claims issues; and delayed, irregular, and/or non-payment of services due to minor and often negligible issues. In addition, there are numerous instances of prior authorization requests filed as far back as May 2006 that have not yet been approved, resulting in unnecessary treatment delays and interrupting the children’s on going treatment regimens. School age children have even been denied treatment because the CMOs incorrectly maintain they will be treated through Individual Education Plans (IEPs) paid through the Department of Education (DOE). These denials occur even when the Plan of Care’s (POCs) medically related goals, as set by the child’s pediatrician, are vastly different from the IEPs educational goals.
The second issue is in regards to the new threshold reduction from 20 units (5 hours) per discipline per month to eight units (2 hours) per discipline per month for occupational therapy, physical therapy, and speech therapy. This threshold is so low that almost all of the children in the CIS program will require a PA to continue their necessary prescribed current level of care, thus resulting in additional and unnecessary paperwork to assist severely involved patients with definite, long-term needs. This will exacerbate current administrative problems for physicians and therapists when medical necessity has already been established by the physician’s order and/or a team of professionals via the Individualized Family Service Plan (IFSP). The proposed threshold reduction follows significant reductions in 2005 and contradicts the eligibility determinations that have already been made for Deeming Waiver eligible children. It has already been established that the PA process for both the CMOs and SSI Medicaid requires numerous forms containing redundant information, but the SSI Medicaid also requires completion of a web application form that requires completion of the same information already required in the paperwork. The process is time intensive, labor intensive, paper intensive and extremely confusing for therapists, doctors and CMO support staff. This is resulting in significant time lags for approval, which ultimately is resulting in children missing needed therapy sessions. With the monetary cuts in reimbursement in the CIS program coupled with the increased paperwork, many private providers will no longer be able to justify the administrative burdens required to perform treatment.
The third issue is that the enrollment process for therapists in the Southwest Georgia Area (SWGA) area is in disarray. Applications were submitted earlier this year and even as far back as last year have still not been processed, and Sep 1 is next Friday. All therapists that are not credentialed before September 1 will be paid at a decreased “out of network” rate, a penalty for which the therapists are not at fault. It is a growing fear that with the present escalating problems regarding changes implemented in June, there will be a snowball effect when the rest of the changes are implemented throughout the state on the first of September. The policy makers at the Department of Community Health (DCH) obviously did not plan for the magnitude of problems that have arisen. We believe they are devising policies for children in an ideal world that does not exist, one in which parents have time to perform the home exercise programs (HEPs) and strategies designed by the therapists to be performed daily. In the real world, parents work, have other children to care for, have meals to cook, dishes to wash, homework to help with, and often just do not have the time necessary to devote to providing therapy with the frequency required by many of these patients. In addition, parents of special needs children are sometimes mentally challenged themselves and don’t remember or understand the HEPs and therapeutic strategies required to keep these children as healthy as possible.
With the issues already identified, it is felt that the new proposed Medicaid strategies will create a significant increase in the administrative time which therapists, physicians, and hospitals will have to spend on an already time-consuming process. We know we will not be able to keep up with the new paperwork requirements regarding PAs for each child. In some cases, providers are refusing to treat Medicaid patients. In other cases, providers have already been forced to go out of business in the North, Metro, and Central regions because of delayed and/or non-payments by the CMO’s. The remaining Georgia areas will feel these same effects. Providers have financial obligations to their agencies, their homes, and their families. With the present changes in place, these same providers are starting to fear that they will not be able to meet their financial obligations and are thus having to make the difficult decision as to whether or not to continue providing services to the children and families that desperately need our care. For many of the families that we serve, there simply are no other options. Even the Babies Can’t Wait (BCW) program, already dealing with shortages of available therapists, is in serious jeopardy as providers are beginning to terminate their contracts in anticipation of the coming changes.
To resolve these issues, the following, high-level suggestions are intended to address those areas that we feel are causing the greatest impacts to our ability to serve the needs of Georgia’s special children.
Increase the units back to 16 units per month or 1 hour per week. This will reduce the number of PAs required and alleviate redundant paperwork.
Streamline the PA process. A single form should be sufficient in lieu of several forms and web portal entries requiring the same information.
Ensure timely payment by CMOs and at the agreed Medicaid rate.
Ensure that the CMOs are training therapist reviewers in policies and procedures for therapy services within the BCW program and in the public school systems to ensure that they can read and interpret an IFSP and IEP if these documents are to be used in determining our services. It is highly recommended that the therapist reviewers have pediatric experience.
Remove BCW children from CMO enrollment.
Technological advances allow physicians to save children born several months premature and even to survive severe medical complications of which they will have severe impairments. The severity of the impairments and the frequency/ duration of therapy required for the child to progress are directly proportional. Yet, therapists are losing the opportunity to treat these children as medically necessary. Research indicates that investment in early intervention results in long-term savings through reduced special education costs, reduced surgeries, and reduced long-term care costs, as well as realizing savings through productive employment and participation in society. If the present changes remain in effect, CIS and early intervention will be losing service providers where critical shortages already exist. DCH’s goal may be to save money now, but in the long run, the state of Georgia will be paying much more if children are not able to continue to receive therapeutic services. Instead of becoming productive members of society, these patients will require increased medical intervention and become even more dependent on the system for the remainder of their lives.
We implore you to reconsider the present changes and consider our suggestions. We appreciate your consideration.
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