“It’s a fight,” 29 percent of Nevada Medicaid claims denied

LAS VEGAS (KLAS) – Paula Cheney and her son Joel have confronted problem after problem.  This time, they’re having bother getting the 13-year-old boy the arm braces that he wants.  In 2022 alone, Nevada Medicaid denied claims for the arm braces at the least thrice.

“It’s like their main goal is to just delay and deny and deny until you just get worn out and you go away,” Cheney informed the I-Team. 

Cheney adopted Joel when he was a toddler, after a journey by means of the kid welfare system which failed him.  He was abused and faraway from his household’s dwelling. Cheney, a foster dad or mum, cared for him.  Joel was then positioned again together with his mom and her boyfriend, as Child Protective Services aimed for reunification.  Joel was abused once more, so badly that he almost died.  Due to brain harm, he’s wheelchair-bound and has a feeding tube.  While Joel’s mom went to jail, Cheney adopted him and offers around-the-clock care.

Cheney mentioned that the arm braces assist to maintain Joel’s arms from curling up, and Nevada Medicaid beforehand permitted them in 2019.  “It’s a need for them. He just outgrew them,” she mentioned.

Nevada Medicaid denies 29 percent of claims general. One company, Gainwell Technologies which handles almost half of the claims for the state denies 37 percent, a spokesman for the Nevada Department of Health and Human Services informed the I-Team.

“It can be frustrating,” mentioned Dr. J.P. Vilai, a pediatrician at Kirk Kerkorian School of Medicine at UNLV. He mentioned as many as 200 kids are seen every day on the pediatric clinic, and plenty of of them are on Nevada Medicaid.

“I think it does seem like they’re requiring more detail, more stipulations and it can be very challenging, very difficult for patients and families to navigate,” Dr. Vilai informed the I-Team.

Hayley Plog is the billing supervisor at Children’s Orthotics and Prosthetics, which offers medical tools and units like Joel’s arm braces.  “If I submit nine authorization requests to Nevada Medicaid, I’ll be lucky if I get one that approves it the first time,” she mentioned.

Plog informed the I-Team that sufferers embrace foster kids, abused kids, and youngsters with particular wants. She mentioned she has even seen claims denied for youngsters in hospice care.  “There are times where it’s hard to not go ahead and get emotional.  There are many times, it’s like I have moments I’m angry,” Plog mentioned.

In circumstances like Joel’s, the declare is time-sensitive, in response to Dr. Vilai.   “With braces particularly, that’s very important,” he mentioned.

Dr. Vilai and Plog each agree that Nevada Medicaid wants to speak with suppliers and be extra clear about pointers.

Cheney mentioned that she reached out to the I-Team concerning the problem to talk up for youngsters like Joel, and oldsters and guardians like herself.  “It’s a fight. It is. Yeah, but then see the thing is, it shouldn’t be this way because I’m fighting, you know, for Joel, but think of all the other Joels,” Cheney informed the I-Team.

After the I-Team reached out to a consultant for Nevada Medicaid, Cheney mentioned a consultant known as to say they might work to resolve the difficulty.

The I-Team additionally requested an interview with a consultant from Nevada Medicaid to debate the difficulty.  No interview was supplied.   A spokesman issued the next assertion:

Nevada Medicaid is prohibited by the Health Insurance Portability and Accountability Act (HIPAA) from discussing particular person circumstances. Therefore, Nevada Medicaid can not verify or deny whether or not such particular person or any particular person, is a Medicaid recipient. Despite our incapability to touch upon a specific case or incident, we will guarantee the individuals of Nevada that when a Medicaid recipient or a Medicaid supplier brings forth a concern, it’s our intention to promptly deal with such concern and resolve it throughout the confines of relevant State and Federal laws. Serving kids with disabilities and their households is a very important position for Nevada Medicaid. Providers can contact [email protected] or 800-525-2395. Members can direct their inquiries to http://dhcfp.nv.gov/Contact/ContactUsForm/

The I-Team’s makes an attempt to achieve a consultant for Gainwell Technologies had been unsuccessful.