The GOTA Medicaid Committee serves as a part of the Trialliance as a liason group with Georgia Medicaid. Members of the committee relay concerns and issues Occupational Therapists in Georgia are experiencing providing services to medicaid clients. Up to date information about meetings between the Trialliance and medicaid are posted on the GOTA listserve and in the medicaid area of the GOTA website.
About six years ago the Trialliance (composed of pediatric therapists from the Georgia Occupational Therapy Association, Georgia Speech-Language Hearing Association, and the Physical Therapy Association of Georgia) began working with the Medicaid staff of the Georgia Department of Community Health (DCH) to address some changes made to the Children’s Intervention Services (CIS) part of the Aged Blind, and Disabled Medicaid program. When DCH began the managed care program for Low Income Medicaid (LIM), many children with chronic disabilities experienced delays and/or denials of therapy services within the EPSDT (Early Periodic Screening, Diagnosis and Treatment) program. EPSDT is a federally mandated part of Medicaid which requires a different standard in determining the need and duration for treatment than that used by traditional managed care organizations. Its definition of medical necessity was enacted in 2008 along with particular standards for therapy services.
Hello GOTA members, (please send this to your colleagues who are not members and URGE them to join GOTA!)
Attached is a copy of a letter that I wrote today to the Governor regarding a questionable situation with one of the Medicaid Care Management Organizations (Peachstate and its subsidary (TRS) Therapy Rehabilitation Systems). Over the past several months, this CMO has
- denied reimbursements (which were pre-approved);
- sent reimbursement checks to practices that bounced and reportedly
- retaliated against practitioners by denying claims when these practitioners complained to DCH (Department of Community Health).
Apparently, Peachstate has been saying that they have limited liability for the lack of reimbursement (and bounced checks) by TRS. Three days ago, they came back to some of the therapists (who were not reimbursed or received "bad" checks) and told them that they would pay them 85% of what they were owed if they signed an agreement not to take this issue any further. What scares me is that they only gave the therapists 3 days to decide whether or not they would sign the agreement.