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

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

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LAS VEGAS (KLAS) – Paula Cheney and her son Joel have faced challenge after challenge.  This time, they are having trouble getting the 13-year-old boy the arm braces that he needs.  In 2022 alone, Nevada Medicaid denied claims for the arm braces at least three times.

“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 told the I-Team. 

Cheney adopted Joel when he was a toddler, after a journey through the child welfare system which failed him.  He was abused and removed from his family’s home. Cheney, a foster parent, cared for him.  Joel was then placed back with his mother and her boyfriend, as Child Protective Services aimed for reunification.  Joel was abused again, so badly that he nearly died.  Due to brain damage, he is wheelchair-bound and has a feeding tube.  While Joel’s mother went to prison, Cheney adopted him and provides around-the-clock care.

Cheney said that the arm braces help to keep Joel’s hands from curling up, and Nevada Medicaid previously approved them in 2019.  “It’s a need for them. He just outgrew them,” she said.

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

“It can be frustrating,” said Dr. J.P. Vilai, a pediatrician at Kirk Kerkorian School of Medicine at UNLV. He said as many as 200 children are seen each day at the pediatric clinic, and many 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 told the I-Team.

Hayley Plog is the billing manager at Children’s Orthotics and Prosthetics, which provides medical equipment and devices 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 said.

Plog told the I-Team that patients include foster children, abused children, and children with special needs. She said she has even seen claims denied for children 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 said.

In cases like Joel’s, the claim is time-sensitive, according to Dr. Vilai.   “With braces particularly, that’s very important,” he said.

Dr. Vilai and Plog both agree that Nevada Medicaid needs to communicate with providers and be more clear about guidelines.

Cheney said that she reached out to the I-Team about the issue to speak up for children like Joel, and parents 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 told the I-Team.

After the I-Team reached out to a representative for Nevada Medicaid, Cheney said a representative called to say they would work to resolve the issue.

The I-Team also requested an interview with a representative from Nevada Medicaid to discuss the issue.  No interview was provided.   A spokesman issued the following statement:

Nevada Medicaid is prohibited by the Health Insurance Portability and Accountability Act (HIPAA) from discussing individual cases. Therefore, Nevada Medicaid cannot confirm or deny whether such individual or any individual, is a Medicaid recipient. Despite our inability to comment on a particular case or incident, we can assure the people of Nevada that when a Medicaid recipient or a Medicaid provider brings forth a concern, it is our intention to promptly address such concern and resolve it within the confines of applicable State and Federal regulations. Serving children with disabilities and their families is a vital role for Nevada Medicaid. Providers can contact NevadaProviderTraining@GainwellTechnologies.com or 800-525-2395. Members can direct their questions to http://dhcfp.nv.gov/Contact/ContactUsForm/

The I-Team’s attempts to reach a representative for Gainwell Technologies were unsuccessful.

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