Re: [MedicaidforHDOT] Other states now reimbursing HBOT?

[Guest guest]

I posed this same question to the list sometime back relative to La. and

received no response.

Makes one wonder what is the current agenda of the list?

Legitimate questions such as those which prompted the formation of the list go

unanswered.

I guess a stupid question like " would the chamber blow up if the patient passed

gas? " would garner more interest than " which states reimburse for HBOT? "

And yes, Mr. Freels, there is a child in La. that receives HBOT and Medicaid is

paying for it. Unfortunately, it's not my child.

My child's request was submitted November 10th and I have not yet received a

formal response. Still hoping for the best...

Kindest regards,

Carroll

188 Trenton Dr.

Slidell, La. 70461

985-643-6719 ph.

985-643-7116 fax

karencarroll@...

visit our family web site

www.home.bellsouth.net/p/pwp-robertkarencarroll

[MedicaidforHDOT] Other states now reimbursing HBOT?

Are there any states now reimbursing HBOT that haven't been?

There's a case pending in New York. Are there others?

At one time there was a NJ family preparing for a hearing.

Any others?

Please post any news.

I'm preparing an article for Hyperbaric Medicine Today.

Thanks.

```````````````````````````````````````````````````````

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770/491-6776 (phone and fax)

720/269-5289 (efax, sends fax as email attachment)

mailto:dfreels@...

http://www.freelanceforum.org/df

[Guest guest]

The answer to the gas question is that the gas still needs ignition. As

for New Mexico, we are having a hearing on January 7th about Medicaid

reimbursement with our state HSD. As of the moment there is no Medicaid

reimbursement.

KP Stoller, MD, FAAP

Assistant Clinical Prof, UNM HSC Dept Pediatrics

Simply Hyperbarics

www.simplyhyperbarics.com

> I posed this same question to the list sometime back relative to La. and

> received no response.

>

> Makes one wonder what is the current agenda of the list?

>

> Legitimate questions such as those which prompted the formation of the

> list go unanswered.

>

> I guess a stupid question like " would the chamber blow up if the patient

> passed gas? " would garner more interest than " which states reimburse for

> HBOT? "

>

> And yes, Mr. Freels, there is a child in La. that receives HBOT and

> Medicaid is paying for it. Unfortunately, it's not my child.

>

> My child's request was submitted November 10th and I have not yet

> received a formal response. Still hoping for the best...

>

> Kindest regards,

>

> Carroll

> 188 Trenton Dr.

> Slidell, La. 70461

> 985-643-6719 ph.

> 985-643-7116 fax

> karencarroll@...

> visit our family web site

> www.home.bellsouth.net/p/pwp-robertkarencarroll

> [MedicaidforHDOT] Other states now reimbursing HBOT?

>

>

> Are there any states now reimbursing HBOT that haven't been?

>

> There's a case pending in New York. Are there others?

>

> At one time there was a NJ family preparing for a hearing.

>

> Any others?

>

> Please post any news.

>

> I'm preparing an article for Hyperbaric Medicine Today.

>

> Thanks.

>

>

> ```````````````````````````````````````````````````````

>

>

> Freels

> 2948 Windfield Circle

> Tucker, GA 30084-6714

> 770/491-6776 (phone and fax)

> 720/269-5289 (efax, sends fax as email attachment)

> mailto:dfreels@...

>

> http://www.freelanceforum.org/df

>

>

>

>

[Guest guest]

, I can only give you my opinion. To my knowledge, no states reimburse

for hbot except on an occasional basis. I think it depends entirely on the

state and who you talk to in that state. We may hear of a state paying here

or there but until we are organized enough to do something, I do not see it

happening in the near future.

There are a couple of individuals that seem to be accomplishing more for us

than all the associations put together. I hope we hear more from them soon.

ICAREnow is a new association that is also growing fast to represent your

rights to alternative therapies of any type that works better than

mainstream medicine. They believe if they can get enough members they can

start some class action lawsuits to force the issue. I agree. Their

website is www.icarenow.org

Does anyone know the website for the IHMA? I did not bookmark it properly

and cannot find it.

Hartsoe

[MedicaidforHDOT] Other states now reimbursing HBOT?

>

>

> Are there any states now reimbursing HBOT that haven't been?

>

> There's a case pending in New York. Are there others?

>

> At one time there was a NJ family preparing for a hearing.

>

> Any others?

>

> Please post any news.

>

> I'm preparing an article for Hyperbaric Medicine Today.

>

> Thanks.

>

>

> ```````````````````````````````````````````````````````

>

>

> Freels

> 2948 Windfield Circle

> Tucker, GA 30084-6714

> 770/491-6776 (phone and fax)

> 720/269-5289 (efax, sends fax as email attachment)

> mailto:dfreels@...

>

> http://www.freelanceforum.org/df

>

>

>

>

[Guest guest]

Dr. Stoller: How did you manage to arrange such a hearing? Perhaps

we can all learn a thing or two from your success.

Lynn

> The answer to the gas question is that the gas still needs

ignition. As

> for New Mexico, we are having a hearing on January 7th about

Medicaid

> reimbursement with our state HSD. As of the moment there is no

Medicaid

> reimbursement.

>

> KP Stoller, MD, FAAP

> Assistant Clinical Prof, UNM HSC Dept Pediatrics

> Simply Hyperbarics

> www.simplyhyperbarics.com

>

> > I posed this same question to the list sometime back relative to

La. and

> > received no response.

> >

> > Makes one wonder what is the current agenda of the list?

> >

> > Legitimate questions such as those which prompted the formation

of the

> > list go unanswered.

> >

> > I guess a stupid question like " would the chamber blow up if the

patient

> > passed gas? " would garner more interest than " which states

reimburse for

> > HBOT? "

> >

> > And yes, Mr. Freels, there is a child in La. that receives HBOT

and

> > Medicaid is paying for it. Unfortunately, it's not my child.

> >

> > My child's request was submitted November 10th and I have not yet

> > received a formal response. Still hoping for the best...

> >

> > Kindest regards,

> >

> > Carroll

> > 188 Trenton Dr.

> > Slidell, La. 70461

> > 985-643-6719 ph.

> > 985-643-7116 fax

> > karencarroll@b...

> > visit our family web site

> > www.home.bellsouth.net/p/pwp-robertkarencarroll

> > [MedicaidforHDOT] Other states now reimbursing HBOT?

> >

> >

> > Are there any states now reimbursing HBOT that haven't been?

> >

> > There's a case pending in New York. Are there others?

> >

> > At one time there was a NJ family preparing for a hearing.

> >

> > Any others?

> >

> > Please post any news.

> >

> > I'm preparing an article for Hyperbaric Medicine Today.

> >

> > Thanks.

> >

> >

> > ```````````````````````````````````````````````````````

> >

> >

> > Freels

> > 2948 Windfield Circle

> > Tucker, GA 30084-6714

> > 770/491-6776 (phone and fax)

> > 720/269-5289 (efax, sends fax as email attachment)

> > mailto:dfreels@m...

> >

> > http://www.freelanceforum.org/df

> >

> >

> >

> >

[Guest guest]

: Your comments bring up a good point - I have gotten the

impression (perhaps mistakenly) that when a state agrees or is forced

to reimburse for HBOT for brain injury, a precedent is set within

that state which makes it impossible (illegal?) for Medicaid to deny

reimbursement to other BI individuals for HBOT. Is this true or

not? If not, than am I to understand that those individuals who are

sitting back waiting for someone else in their state to take the bull

by the horns and win reimbursement are apparently placing their eggs

in the wrong basket?

Lynn

> , I can only give you my opinion. To my knowledge, no states

reimburse

> for hbot except on an occasional basis. I think it depends

entirely on the

> state and who you talk to in that state. We may hear of a state

paying here

> or there but until we are organized enough to do something, I do

not see it

> happening in the near future.

>

> There are a couple of individuals that seem to be accomplishing

more for us

> than all the associations put together. I hope we hear more from

them soon.

>

> ICAREnow is a new association that is also growing fast to

represent your

> rights to alternative therapies of any type that works better than

> mainstream medicine. They believe if they can get enough members

they can

> start some class action lawsuits to force the issue. I agree.

Their

> website is www.icarenow.org

>

> Does anyone know the website for the IHMA? I did not bookmark it

properly

> and cannot find it.

>

> Hartsoe

>

> [MedicaidforHDOT] Other states now reimbursing HBOT?

> >

> >

> > Are there any states now reimbursing HBOT that haven't been?

> >

> > There's a case pending in New York. Are there others?

> >

> > At one time there was a NJ family preparing for a hearing.

> >

> > Any others?

> >

> > Please post any news.

> >

> > I'm preparing an article for Hyperbaric Medicine Today.

> >

> > Thanks.

> >

> >

> > ```````````````````````````````````````````````````````

> >

> >

> > Freels

> > 2948 Windfield Circle

> > Tucker, GA 30084-6714

> > 770/491-6776 (phone and fax)

> > 720/269-5289 (efax, sends fax as email attachment)

> > mailto:dfreels@m...

> >

> > http://www.freelanceforum.org/df

> >

> >

> >

> >

[Guest guest]

First, I have a child with CP whose parents are willing to go through,

jump through and get strangled by all the hoops of the system. I treated

their daughter and after only 40 treatments their were significant

documented gains in all muscular and cognitive areas. Then we went

throught the Medicaid rejections. Then we plugged her into a group called

Protection & Advocacy who asigned her lawyers, and now we are going for a

hearing with the HSD of NM. We are not optimistic about the results, but

that will just mean their will be another CP child taking a State to

court. First Georgia, then PA, and now NM. How many will it take

before????

Damn the AHRQ report that came out two months ago!!!!!!!!!!!!!!

KP Stoller, MD, FAAP

Assistant Clinical Prof, UNM HSC Dept Pediatrics

Simply Hyperbarics

www.simplyhyperbarics.com

> Dr. Stoller: How did you manage to arrange such a hearing? Perhaps we

> can all learn a thing or two from your success.

>

> Lynn

>

>

>> The answer to the gas question is that the gas still needs

> ignition. As

>> for New Mexico, we are having a hearing on January 7th about

> Medicaid

>> reimbursement with our state HSD. As of the moment there is no

> Medicaid

>> reimbursement.

>>

>> KP Stoller, MD, FAAP

>> Assistant Clinical Prof, UNM HSC Dept Pediatrics

>> Simply Hyperbarics

>> www.simplyhyperbarics.com

>>

>> > I posed this same question to the list sometime back relative to

> La. and

>> > received no response.

>> >

>> > Makes one wonder what is the current agenda of the list?

>> >

>> > Legitimate questions such as those which prompted the formation

> of the

>> > list go unanswered.

>> >

>> > I guess a stupid question like " would the chamber blow up if the

> patient

>> > passed gas? " would garner more interest than " which states

> reimburse for

>> > HBOT? "

>> >

>> > And yes, Mr. Freels, there is a child in La. that receives HBOT

> and

>> > Medicaid is paying for it. Unfortunately, it's not my child.

>> >

>> > My child's request was submitted November 10th and I have not yet

>> received a formal response. Still hoping for the best...

>> >

>> > Kindest regards,

>> >

>> > Carroll

>> > 188 Trenton Dr.

>> > Slidell, La. 70461

>> > 985-643-6719 ph.

>> > 985-643-7116 fax

>> > karencarroll@b...

>> > visit our family web site

>> > www.home.bellsouth.net/p/pwp-robertkarencarroll

>> > [MedicaidforHDOT] Other states now reimbursing HBOT?

>> >

>> >

>> > Are there any states now reimbursing HBOT that haven't been?

>> >

>> > There's a case pending in New York. Are there others?

>> >

>> > At one time there was a NJ family preparing for a hearing.

>> >

>> > Any others?

>> >

>> > Please post any news.

>> >

>> > I'm preparing an article for Hyperbaric Medicine Today.

>> >

>> > Thanks.

>> >

>> >

>> > ```````````````````````````````````````````````````````

>> >

>> >

>> > Freels

>> > 2948 Windfield Circle

>> > Tucker, GA 30084-6714

>> > 770/491-6776 (phone and fax)

>> > 720/269-5289 (efax, sends fax as email attachment)

>> > mailto:dfreels@m...

>> >

>> > http://www.freelanceforum.org/df

>> >

>> >

>> >

>> >

[Guest guest]

>First, I have a child with CP whose parents are willing to go through,

>jump through and get strangled by all the hoops of the system. I treated

>their daughter and after only 40 treatments their were significant

>documented gains in all muscular and cognitive areas. Then we went

>throught the Medicaid rejections. Then we plugged her into a group called

>Protection & Advocacy who asigned her lawyers, and now we are going for a

>hearing with the HSD of NM. We are not optimistic about the results, but

>that will just mean their will be another CP child taking a State to

>court. First Georgia, then PA, and now NM. How many will it take

>before????

Dr. Stoller,

Where did the denials come from?

Whose name is on the letterhead of the written denial(s)?

Were the denials from the New Mexico Medical Review Association

(http://www.nmmra.org)?

>

>Damn the AHRQ report that came out two months ago!!!!!!!!!!!!!!

>

The lead author was Mark Helfand, a highly-opinionated epidemiologist I met

3 or 4 years ago on another listserv on medical decision-making.

I posted our correspondence here earlier. At one point Helfand even impled

that Philip was promoting HBOT for personal financial gain. If at all

possible I would try to use those emails if that AHRQ report was used as a

reason for denial.

Also, while Helfand is the lead author, it's my understanding that the

primary investigator was not an MD but a pharmacist who dismissed something

like 90% of the HBOT literature because they weren't double-blind

controlled studies and that's why they gave so much credibility to the

Collet farce.

Also, the meeting with Pierre Marois in Ft. Lauderdale where he detailed

what actually happened with Collet was tape recorded, and I can copy it for

you if you think it will help. Ask the attorneys. Evidence rules may not

allow it.

However, it could be very important if you can find out if the New Mexico

Medical Review Association had anything to do with the review and denial.

That's absolutely essential. Please let me know as soon as possible.

```````````````````````````````````````````````````````

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770/491-6776 (phone and fax)

720/269-5289 (efax, sends fax as email attachment)

mailto:dfreels@...

http://www.freelanceforum.org/df

[Guest guest]

I think if it set a precedent, that state would be bombarded with people

wanting to do HBOT. I think each case will have to be handled

independently. Sitting back and waiting is not going to accomplish

anything. In my opinion it will take a class action suit, probably in each

state, or at least in a half dozen states to get it going. I don't see that

happening because there is no organization which will sponsor it unless

ICAREnow gets going. If everyone would join ICAREnow (no membership dues),

we could make it happen. www.icarenow.org

[MedicaidforHDOT] Other states now reimbursing HBOT?

> > >

> > >

> > > Are there any states now reimbursing HBOT that haven't been?

> > >

> > > There's a case pending in New York. Are there others?

> > >

> > > At one time there was a NJ family preparing for a hearing.

> > >

> > > Any others?

> > >

> > > Please post any news.

> > >

> > > I'm preparing an article for Hyperbaric Medicine Today.

> > >

> > > Thanks.

> > >

> > >

> > > ```````````````````````````````````````````````````````

> > >

> > >

> > > Freels

> > > 2948 Windfield Circle

> > > Tucker, GA 30084-6714

> > > 770/491-6776 (phone and fax)

> > > 720/269-5289 (efax, sends fax as email attachment)

> > > mailto:dfreels@m...

> > >

> > > http://www.freelanceforum.org/df

> > >

> > >

> > >

> > >

[Guest guest]

THe Medicaid program in NM is administered by several insurance programs

that take on what is called " Salud " patients. In this case, my patient has

Lovelace Salud. Lovelace used to be owned by CIGNA, but they sold it to

someone else and I can't remember who at this moment.

Lovelace rejected her twice, but that was very much expected. THey are the

bottom gatekeepers. The HSD has the the AHRQ that they are waving around,

which as you know is the equivalent of the Warren COmmission report on

using HBO for CP and Stroke.

KP Stoller, MD, FAAP

Assistant Clinical Prof, UNM HSC Dept Pediatrics

Simply Hyperbarics

www.simplyhyperbarics.com

>>First, I have a child with CP whose parents are willing to go through,

>> jump through and get strangled by all the hoops of the system. I

>> treated their daughter and after only 40 treatments their were

>> significant documented gains in all muscular and cognitive areas. Then

>> we went throught the Medicaid rejections. Then we plugged her into a

>> group called Protection & Advocacy who asigned her lawyers, and now we

>> are going for a hearing with the HSD of NM. We are not optimistic about

>> the results, but that will just mean their will be another CP child

>> taking a State to court. First Georgia, then PA, and now NM. How many

>> will it take

>>before????

>

>

> Dr. Stoller,

>

> Where did the denials come from?

>

> Whose name is on the letterhead of the written denial(s)?

>

> Were the denials from the New Mexico Medical Review Association

> (http://www.nmmra.org)?

>

>

>

>

>>

>>Damn the AHRQ report that came out two months ago!!!!!!!!!!!!!!

>>

>

> The lead author was Mark Helfand, a highly-opinionated epidemiologist I

> met 3 or 4 years ago on another listserv on medical decision-making.

>

> I posted our correspondence here earlier. At one point Helfand even

> impled that Philip was promoting HBOT for personal financial gain.

> If at all possible I would try to use those emails if that AHRQ report

> was used as a reason for denial.

>

> Also, while Helfand is the lead author, it's my understanding that the

> primary investigator was not an MD but a pharmacist who dismissed

> something like 90% of the HBOT literature because they weren't

> double-blind

> controlled studies and that's why they gave so much credibility to the

> Collet farce.

>

> Also, the meeting with Pierre Marois in Ft. Lauderdale where he detailed

> what actually happened with Collet was tape recorded, and I can copy it

> for you if you think it will help. Ask the attorneys. Evidence rules may

> not allow it.

>

> However, it could be very important if you can find out if the New

> Mexico Medical Review Association had anything to do with the review and

> denial. That's absolutely essential. Please let me know as soon as

> possible.

>

>

>

> ```````````````````````````````````````````````````````

>

>

> Freels

> 2948 Windfield Circle

> Tucker, GA 30084-6714

> 770/491-6776 (phone and fax)

> 720/269-5289 (efax, sends fax as email attachment)

> mailto:dfreels@...

>

> http://www.freelanceforum.org/df

>

>

>

>

> _._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._.

> Join the International Hyperbaric Medical Association

> http://www.hyperbaricmedicalassociation.org/forms/Friends_of_IHMA_Join.pdf

>

> Unrestricted downloads of 50+ pdf files on HBOT efficacy

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> HDO-documentation/files/ and

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>

> Download your state EPSDT program

> http://www.hcfa.gov/medicaid/stateplan/Map.asp by doing a search on the

> word " ameliorate " . State Medicaid websites

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>

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>

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>

[Guest guest]

Good luck to all of you! How many will it take, indeed....

Lynn

> >> The answer to the gas question is that the gas still needs

> > ignition. As

> >> for New Mexico, we are having a hearing on January 7th about

> > Medicaid

> >> reimbursement with our state HSD. As of the moment there is no

> > Medicaid

> >> reimbursement.

> >>

> >> KP Stoller, MD, FAAP

> >> Assistant Clinical Prof, UNM HSC Dept Pediatrics

> >> Simply Hyperbarics

> >> www.simplyhyperbarics.com

> >>

> >> > I posed this same question to the list sometime back relative

to

> > La. and

> >> > received no response.

> >> >

> >> > Makes one wonder what is the current agenda of the list?

> >> >

> >> > Legitimate questions such as those which prompted the formation

> > of the

> >> > list go unanswered.

> >> >

> >> > I guess a stupid question like " would the chamber blow up if

the

> > patient

> >> > passed gas? " would garner more interest than " which states

> > reimburse for

> >> > HBOT? "

> >> >

> >> > And yes, Mr. Freels, there is a child in La. that receives HBOT

> > and

> >> > Medicaid is paying for it. Unfortunately, it's not my child.

> >> >

> >> > My child's request was submitted November 10th and I have not

yet

> >> received a formal response. Still hoping for the best...

> >> >

> >> > Kindest regards,

> >> >

> >> > Carroll

> >> > 188 Trenton Dr.

> >> > Slidell, La. 70461

> >> > 985-643-6719 ph.

> >> > 985-643-7116 fax

> >> > karencarroll@b...

> >> > visit our family web site

> >> > www.home.bellsouth.net/p/pwp-robertkarencarroll

> >> > [MedicaidforHDOT] Other states now reimbursing HBOT?

> >> >

> >> >

> >> > Are there any states now reimbursing HBOT that haven't been?

> >> >

> >> > There's a case pending in New York. Are there others?

> >> >

> >> > At one time there was a NJ family preparing for a hearing.

> >> >

> >> > Any others?

> >> >

> >> > Please post any news.

> >> >

> >> > I'm preparing an article for Hyperbaric Medicine Today.

> >> >

> >> > Thanks.

> >> >

> >> >

> >> > ```````````````````````````````````````````````````````

> >> >

> >> >

> >> > Freels

> >> > 2948 Windfield Circle

> >> > Tucker, GA 30084-6714

> >> > 770/491-6776 (phone and fax)

> >> > 720/269-5289 (efax, sends fax as email attachment)

> >> > mailto:dfreels@m...

> >> >

> >> > http://www.freelanceforum.org/df

> >> >

> >> >

> >> >

> >> >

[Guest guest]

>THe Medicaid program in NM is administered by several insurance programs

>that take on what is called " Salud " patients. In this case, my patient has

>Lovelace Salud. Lovelace used to be owned by CIGNA, but they sold it to

>someone else and I can't remember who at this moment.

>

>Lovelace rejected her twice, but that was very much expected. THey are the

>bottom gatekeepers. The HSD has the the AHRQ that they are waving around,

>which as you know is the equivalent of the Warren COmmission report on

>using HBO for CP and Stroke.

>

Dr. Stoller (and other list members too),

Please read this and understand what it means for you and your state

Medicaid plan. This is going to get into some of the intricacies of

Medicaid bureaucracy, but I believe it's critical for everybody to

understand this.

I didn't understand this myself until a few months ago, and up until

yesterday I have been in close correspondence with Tom Scully, the director

of CMS in an effort to clear up this snag.

While the NM Medicaid program may be administered by several insurance

programs, it's quite possible that the actual decision to deny came from

the New Mexico Medical Review Association (http://www.nmmra.org).

The New Mexico Medical Review Association is a Medicare Quality Improvement

Organization (QIO). Every state has a QIO, which used to be known as a Peer

Review Organization (PRO), which is the local (state) medical-decision

making arm of HCFA/CMS.

The QIOs/PROs were created by Medicare/HCFA to make decisions on services

for beneficiaries in each state. They are quasi-public/quasi-private and

therefore something of a mystery and an enigma in terms of who regulates

them, i.e., who regulates the regulators.

In Georgia, our denial technically came from the Georgia Department of

Medical Assistance (Georgia Medicaid); however, the people who actually did

the leg work, the review for the request of services was the Georgia

QIO--the Georgia Medical Care Foundation (GMCF: http://www.gmcf.org).

State Medicaid agencies are hiring the QIOs to make medical decisions,

believing their state plans are duplicates of the Medicare plans. In turn

the QIOs are *contractually bound* to only allow Medicaid services which

are covered by the state Medicaid plan.

Because Paragraph 5 *specifically dictates* that states pay for all

services " necessary to correct or ameliorate " , " whether or not such

services are covered under the State plan " , this creates an inherent and

insurmontable conflict of interest for the QIO--which is why nearly every

state has denied off-label HBOT and parents have had to go to court to get

off-label hyperbaric oxygen.

I have explained all of this in minute detail to CMS Director Scully who

has been reviewing it and is very interested in finding the extent of the

problem.

He sees that if the Quality Improvement Organizations were really

interested in improving quality and were really organized, they would (1)

acknowledge the QIO conflict of interest, (2) inform their states of the

conflict of interest, (3) inform their states and other QIOs about HBOT

efficacy in pediatric brain-injury.

Here's what we need to do. All of us--even those folks who have

successfully gotten their state Medicaid agencies to pay for off-label

HBOT. We need to get documentation that the denials are coming from,

originating from the QIOs.

That's why I'm asking where the NM denials came from. Whose name is on the

letterhead of the written denial(s)?

Were the denials from the New Mexico Medical Review Association

(http://www.nmmra.org)?

Let's find out. We've got congressional hearings in three or four months.

Let's load up with some ammo.

```````````````````````````````````````````````````````

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770/491-6776 (phone and fax)

720/269-5289 (efax, sends fax as email attachment)

mailto:dfreels@...

http://www.freelanceforum.org/df

[Guest guest]

>THe Medicaid program in NM is administered by several insurance programs

>that take on what is called " Salud " patients. In this case, my patient has

>Lovelace Salud. Lovelace used to be owned by CIGNA, but they sold it to

>someone else and I can't remember who at this moment.

>

>Lovelace rejected her twice, but that was very much expected. THey are the

>bottom gatekeepers. The HSD has the the AHRQ that they are waving around,

>which as you know is the equivalent of the Warren COmmission report on

>using HBO for CP and Stroke.

>

Dr. Stoller (and other list members too),

Please read this and understand what it means for you and your state

Medicaid plan. This is going to get into some of the intricacies of

Medicaid bureaucracy, but I believe it's critical for everybody to

understand this.

I didn't understand this myself until a few months ago, and up until

yesterday I have been in close correspondence with Tom Scully, the director

of CMS in an effort to clear up this snag.

While the NM Medicaid program may be administered by several insurance

programs, it's quite possible that the actual decision to deny came from

the New Mexico Medical Review Association (http://www.nmmra.org).

The New Mexico Medical Review Association is a Medicare Quality Improvement

Organization (QIO). Every state has a QIO, which used to be known as a Peer

Review Organization (PRO), which is the local (state) medical-decision

making arm of HCFA/CMS.

The QIOs/PROs were created by Medicare/HCFA to make decisions on services

for beneficiaries in each state. They are quasi-public/quasi-private and

therefore something of a mystery and an enigma in terms of who regulates

them, i.e., who regulates the regulators.

In Georgia, our denial technically came from the Georgia Department of

Medical Assistance (Georgia Medicaid); however, the people who actually did

the leg work, the review for the request of services was the Georgia

QIO--the Georgia Medical Care Foundation (GMCF: http://www.gmcf.org).

State Medicaid agencies are hiring the QIOs to make medical decisions,

believing their state plans are duplicates of the Medicare plans. In turn

the QIOs are *contractually bound* to only allow Medicaid services which

are covered by the state Medicaid plan.

Because Paragraph 5 *specifically dictates* that states pay for all

services " necessary to correct or ameliorate " , " whether or not such

services are covered under the State plan " , this creates an inherent and

insurmontable conflict of interest for the QIO--which is why nearly every

state has denied off-label HBOT and parents have had to go to court to get

off-label hyperbaric oxygen.

I have explained all of this in minute detail to CMS Director Scully who

has been reviewing it and is very interested in finding the extent of the

problem.

He sees that if the Quality Improvement Organizations were really

interested in improving quality and were really organized, they would (1)

acknowledge the QIO conflict of interest, (2) inform their states of the

conflict of interest, (3) inform their states and other QIOs about HBOT

efficacy in pediatric brain-injury.

Here's what we need to do. All of us--even those folks who have

successfully gotten their state Medicaid agencies to pay for off-label

HBOT. We need to get documentation that the denials are coming from,

originating from the QIOs.

That's why I'm asking where the NM denials came from. Whose name is on the

letterhead of the written denial(s)?

Were the denials from the New Mexico Medical Review Association

(http://www.nmmra.org)?

Let's find out. We've got congressional hearings in three or four months.

Let's load up with some ammo.

```````````````````````````````````````````````````````

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770/491-6776 (phone and fax)

720/269-5289 (efax, sends fax as email attachment)

mailto:dfreels@...

http://www.freelanceforum.org/df