DFCS and Medicaid: Managing Crazy

If you live in Georgia, perhaps you read this article in the Atlanta Journal Constitution: 17,000 Georgians cut off from Medicaid face messy bureaucracy.  If you didn’t, let me tell you the short version.  Basically, the Department of Family and Child Services (DFCS) issued denial letters for 17,000 Georgians because of they did not properly renew their Medicaid application.  A subsequent article told how an additional 13,000 Georgians were also denied Medicaid benefits.  Fortunately, the state decided to reinstate everyone for an additional year after the article was posted, but what a scary experience for an individual dependent on these benefits.

DFCS claimed that they properly communicated with the Medicaid members by email; however, representative attorneys convincingly claimed that no such communication reach the members email box.  Many, if not most, Medicaid members in Georgia are Aged, Blind, or Disabled (ABD).  Often, these individuals require enormous assistance because of their health status.

If you were to read this article, you would be excused if you thought it were a solitary experience.  It is not.  It is business as usual.  DFCS makes all Medicaid eligibility decisions.  The decision must be made every year.  The process is lengthy.  It is difficult to manage. It is difficult to find out any information.  The process affects Georgians negatively every single day.  Georgians lose eligibility often.

Let me share an example of one of our members at Skylark.  We serve a young man with significant disabilities.  He’s as nice as he can be, but he is unable to fend for himself.  He recently applied for the Elderly and Disabled Waiver Program (EDWP).  To be eligible for this program, he must qualify medically and financially.  When he qualified medically and it looked like he was going to qualify financially, he was authorized to receive services.  He was admitted to a personal care home and to adult day. 

This was a provisional admission.  He then had to pass the gauntlet of Medicaid eligibility with DFCS.  This means that the providers don’t get paid.  He and his family agree to guarantee the payment of the services should he not be deemed eligible for services.  Ten months after the program, DFCS has not granted eligibility.  Actually, they denied him eligibility but didn’t tell anyone.  The bill for the services rendered over the passed 10 months is easily more than $20,000.  Because of the denial, the provider is unlikely to be paid.  Worse, the young man will be discharged from his new home and denied continued services that are very much needed.  He will also be required to repay that $20,000 even though he has no financial resources to do so. 

The good news is that DFCS failed to mail the denial letter.  We escalated the case through the Georgia Department of Community Health.  We quickly discovered that DFCS evaluated the young man for the wrong type of Medicaid, which meant that he was indeed eligible for services.  The case was reopened. The family was required to resubmit all the documentation again (after it had been submitted properly before, then lost at DFCS, and then resubmitted again).  We expect that he will likely receive a letter with good news shortly. 

We have other Medicaid members who completely miss the annual reauthorization required by DFCS. Or they have to resubmit applications repeatedly. Or they have to appeal erroneous decisions.

I wish this story were unique. Or that the denial of Medicaid benefits to 30,000 Georgians surprised me.  But it is not, and I am not surprised.  I learned recently that the Medicaid waiver management division consistently has over 100 cases like this open at any given time.  One of the larger care management agencies for the EDWP has over 500 cases open at any given time.  These six hundred cases are only a drop in the bucket as there are over 12 other case management agencies with the same problem.  It will get worse as the SOURCE program will soon have to go through the eligibility process.  This more than doubles the case load for DFCS for evaluating applications to EDWP. It gets worse again as all nursing homes, hospitals, and other Medicaid using health services must use this same evaluation system. 

This process is brutal for individuals and families.  Many of these families are caring for individuals with Alzheimer’s disease and other dementias, and intellectual and developmental disabilities.  In other words, these individuals can’t help themselves through this process.

It is also brutal for the businesses that serve these individuals and families.  One business reported having to write off over $40,000 because of services rendered to individuals ultimately denied services.  Another business reported that they have a current balance of over $20,000. They expect to write off about $7-10,000 of that because of a delayed eligibility process.  Another business reports rationing access to their services to manage the risks associated with the DFCS eligibility process. 

What is a business to do?

We focus on the affected individual first.  This means that we know the system well and know how to escalate problems within the regulatory environment.  We are often able to help the family navigate the process.

We are also a business.  We have to pay rent, pay employees, pay insurance.  Earned revenue without cash payments drives us towards bankruptcy, so there is a limit to how long we can provide services without payment.   So, some are discharged. Or, families stretch to find the resources to pay for a few months of service with a promise of repayment if and when eligibility is granted. 

Finally, this situation demonstrates the need for a small business to have a public policy and government relations strategy.  In this environment, the business needs:

  1. A good relationship with the regulatory agencies.  Let me rephrase.  Develop a good relation with the right employees in the regulatory agencies who know how to get things done within the bureaucracy.
  2. To be a great member of your local and state trade association.  The association that represents multiple players in an industry develops credibility for the long haul with legislators and agency heads.  It is often true that the association is the only players who can open doors and effectively address challenges.
  3. Persistence.  Face it, when dealing with the government, nothing happens quickly. It takes time, a lot of work, and being the squeaky wheel.
  4. To make Government Relations a priority.

This DFCS problem needs to be solved.  There are millions of dollars at stake.  The lives of the most vulnerable Georgians are adversely affected.  It won’t be a quick resolution as DFCS isn’t responsive, and the problem has been growing for years.  I’m hopeful that our association will jump on it.  This problem probably requires a legislative solution, which makes solving the problem even more complicated.

Yet, perhaps the Atlanta Journal Constitution article can demonstrate the impact on 30,000 Georgians to the Governor and the Legislature.

What else? How does Government Relations figure into your business?

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