Family struggles with Managed Care Organization to get hospital bills paid
Iowa’s switch to a managed Medicaid system last year has one Cedar Rapids family wondering who’s going to pay the hospital bill for a disabled 35-year-old son.
Under Iowa’s privatized program, three managed care organizations, or MCOs, care for patients who qualify for Medicaid. The three companies that won contracts were AmeriHealth Caritas, UnitedHealthcare and AmeriGroup.
Members of Brandon Beaty’s family say they chose AmeriHealth last year because that company allowed them to keep a case worker familiar with the disabled man’s case.
When Beaty’s family took him to the emergency room at Mercy Medical Center last week, they expected a hospital stay. Beaty has Down’s Syndrome and also received a kidney transplant. He was suffering from a virus and had severe diarrhea and dehydration.
Doctor’s admitted Beaty because hospital monitoring was needed since chemical imbalances for a transplant recipient, if uncorrected, could have killed him.
Donald Dykes, Beaty’s stepfather, says it’s the kind of medical situation where you don’t want to take chances.
“We’re talking kidney failure. He’s only got one and I donated that kidney so I have a vested interest in this and I don’t really care what they say,” Dykes said.
What upset him and other members of the disabled man’s family is how AmeriHealth responded to the hospitalization request. Despite the advice of several doctors, the MCO concluded Beaty didn’t have a fever at the time as well as the other issues and so could get any treatment as an outpatient at home.
Maria Corey, Beaty’s sister and legal co-guardian, said the family was beyond frustrated.
“This is the first time we’ve had any problems with the doctors saying he needs to do this and then the insurance company saying no we’re not going to pay for that,” she said.
Despite the uncertainty about coverage, the family kept Beaty at the hospital for monitoring.
Hospital officials couldn’t talk about his particular case due to privacy rules. But Dr. Timothy Quinn, chief of clinical operations at Mercy, says administrators too are getting frustrated with the new managed care companies constantly overruling medical decisions.
“We face challenges on a daily basis as opposed to somewhat infrequent in the past (under Medicaid). So every day we’re appealing trying to get admissions to hospitals or outside of hospital services for patients that are desperately needed,” Dr. Quinn said.
Beaty may be stable enough to go home soon. But both the hospital and his family are struggling to get the MCO to reverse the decision and pay for the care they say he needed to survive. Without a reversal, the bill would either go to the family or would be absorbed by the hospital as charity care.
A spokesperson for AmeriHealth says the company could not discuss individual circumstances in this case, again for medical privacy rules, but she did share a statement of how the MCO evaluates claims such as Beaty’s.
“What we can share is that each member’s health is evaluated individually and appropriate medical criteria are used in all situations. The health and well-being of our members is our top priority.”