Dear Health and Human Services Commission (HHSC) Director and Texas Legislators:
I am writing to you today as a parent, therapy provider, and concerned citizen regarding the significant delays Texas Medicaid is currently experiencing with authorizations which are drastically affecting continuity of care and quality of life for my son and thousands of Texas children. These delays seem to be a direct result of recent legislation passed to decrease funding to the Texas Medicaid program by approximately $350 million (Rider 50). While the proposed budget cut is currently on hold due to a court injunction, it would appear HHSC has implemented these cuts in the form of delaying authorizations in effort to save the program money.
As a provider, here is just one such example. I received an authorization September 15, 2016 at 7:15 pm via fax. Our office submitted this authorization request on August 1, 2016 – 46 days ago. This letter is dated September 1, 2016 and the authorization period begins on August 15, 2016. The Texas Medicaid Provider manual states that services will not be compensated for without an authorization and authorizations will not be backdated, so therefore, we as providers, must tell our therapists that they cannot see their patients until authorization is received or we risk not receiving payment for services rendered. In this case, our therapist has not seen their patient since the evaluation was performed on August 1st. Now, here we are 46 days later and we find out that 15 days ago our authorization was approved and backdated an additional 15 days, so our patient has missed a month of therapy because we were not notified in a timely manner. Furthermore, our request was for two visits per week and the reviewer denied our request suggesting our patient only required one visit a week due to “slow progress toward therapy goals. “ This is only one example of many we have personally experienced and the countless more we know other patients and providers to be currently experiencing across the state. On average, our authorization requests are taking 4-6 weeks to be approved, if no additional information is requested. If Texas Medicaid & Healthcare Partnership (TMHP) requests additional information, the delay is an additional 2-3 weeks, at minimum. Per the TMHP manual, we cannot submit authorization requests more than 30-days prior to the expiration of a current authorization rendering us unable to be proactive and submit requests 4-6 weeks in advance. As a result, with the current timeline of approval our patients are experiencing 2-3 week lapses in therapy service, and sometimes greater.
These delays are detrimental to the health and well being of our patients. One month without therapy can cause significant regression for chronically ill and long-term disabled children. To add insult to injury, our patients are experiencing regression and loss of skills due to authorization delays and when our request is reduced to once a week visits instead of twice a week, our patients do not have adequate service to reach their prior level of skill nor continue to make significant progress toward goals. Progress is slow because our therapists have to take several steps backward to get our patients back to where they were before there was a lapse in treatment. And then attempt to make progress toward the goals previously set.
The authorization delays directly coincide with the time period in which the court issued an injunction to delay implementation of Rider 50, which would reduce payment for therapy providers. Thousands of children across the state are experiencing lapses of 3 weeks or greater, which, in turn, is undoubtedly saving the state a great deal of money. This seemingly underhanded attempt to implement the budget cut despite court rulings is gross negligence and directly impacting the lives of our children. For many children, therapy is required to maintain current level of function, to decrease the chance of contractures or serious injury, to ensure safety in the environment, to improve and strengthen fine and gross motor skills, to teach speech, to correct speech deficits, to ensure safe feeding, to improve quality of life by teaching skills that will allow children to interact with their peers, and for so many other reasons. Therapy is a cornerstone of ensuring proper development in children.
Additionally, providers have tried to address these concerns with TMHP reviewers and we are told that authorizations are going to nurse review and there is no time period for which they must be approved. Meanwhile, parents are calling TMHP and the Medicaid Ombudsman’s office and being told that authorizations should be approved within 3 business days. As a result, our patients assume it is the providers delaying the authorization and we are losing the trust and rapport we have worked hard to earn from our patients.
The lives of our state’s most vulnerable citizens seem to constantly hang in the balance while legislators and state departments toy with policies looking to save money all while harming the lives of children. It is clear that the powers that be do not understand the needs of special needs community nor do they know how to meet those needs. As a result, children across the state are currently without the necessary services that would improve their quality of life. This issue needs to be rectified immediately. As it stands, the state is currently profiting off of the steady decline in health and absence of service for our children, which is simply abhorrent, to say the least.
I hope your respective offices will look in to the matter and ensure corrective action will be taken. My son has a life-long disability and depends on therapy services to provide him his best chance at success in life. The issues I continue to see with Texas Medicaid provide me with little hope for his future. I know that one day soon, his service will be denied, as it has been for several of our chronic patients, because what we see as leaps of progress, you deem to be “too little” progress. While Texas is historically a pro-life state, the state places little value on the lives of the disabled, which is evident when legislation passes that can directly harm their lives. It is unfortunate when families like ours rely on the Texas Medicaid program, even as a secondary insurance (as we do), because without it we simply could not afford the staggering costs associated with caring for a disabled family member, only to have that crucial support ripped away due to systemic downfalls and budget cuts.
As you prepare for the next legislative session, it is my hope you will have greater consideration for the lives of your most vulnerable citizens. They are your sons, daughters, nieces, nephews, grandchildren, and they desperately need you to speak up for them in these matters because they deserve the right to a full life. They deserve access to quality healthcare, to programs that enrich their lives, to services that will enable them to become successful tax-paying citizens. We, the families, the providers, the taxpayers, hope for a resolution – sooner rather than later.
Sincerely and with hope,
A Texas Mother looking out for her son and the lives of all Texas children