When A Managed Care Plan “Lost” the Paper Work for an Appeal, PHLP Stepped In
Derek is a 24-year-old on the autism spectrum. He had been receiving occupational therapy--paid for by his Medicaid managed care company--since November 2015, which helps improve his personal hygiene, feeding, and other daily functional tasks. Suddenly, in June, his occupational therapist’s request to continue services was denied by his managed care company. His mom filed an appeal and contacted the Health Law Project. We helped the family prepare evidence (e.g., a detailed progress report from Derek’s therapist and a letter from his physician), which was then forwarded to the managed care company.
When there was no response to the appeal from the managed care company, Derek’s mom contacted them only to be told they had no record of the appeal, the therapist's report, or the physician's letter! Fortunately, Derek’s mom had made a copy of the envelope with the post mark from the postage meter before she mailed it and the occupational therapist’s report had been sent with postal tracking. PHLP brought this to the attention of state Medicaid officials who oversee the managed care company and they contacted the company. Within a day, the managed care company not only “found” the appeal and the supporting medical documents, but reversed their decision--authorizing all the occupational therapy visits requested.
Pennsylvania is one of the few states in the country with a non-profit law firm exclusively focused on health care. The backbone of our work, and the wellspring of our expertise, is helping individuals 1) obtain and keep health insurance OR 2) who have had health services denied, reduced or terminated. In PHLP’s experience consumers like Derek are more successful when they receive expert guidance about adverse benefit determinations.