Another Fun Work Story

My job is not really that bad. These things only happen every now and then. Thankfully.

First a little description of how the Medicaid system works for kids who need therapy. Medicaid will pay for the evaluation (and reimburses us at a surprisingly high rate!) and then our business office sends my report and treatment plan off to the patient's doctor for a signature. Once we receive that, we send the whole package (authorization request, reports, and doc's signature) off to Medicaid for approval. Don't get me wrong, they've really streamlined the process and sometimes the biggest holdup is the doctor's office. But the whole process takes at least a month if everything goes smoothly. The authorizations are usually for six month's worth of twice weekly sessions. Then a month before it expires, we do the entire process all over again to renew. (Let me tell you how much kids enjoy testing every six months...)

Enter my twelve year old patient. He's so far behind I could write a goal for anything and it would probably help him. We did the first six months of therapy and when it came time for the second authorization, they "partially denied" and gave us only three months. Without getting into too many specifics, their reasoning was that the goals we were working on were of "an educationally-based nature and would more effectively be addressed by the educational system." Ha, Right.

I bit the bullet and changed some of the goals. Like I said, we could work on almost anything. But now it has come time to renew again. This week we retested (which he was super thrilled about) and I spent at least an hour yesterday carefully crafting very precise wording about why I had chosen the particular test which was different from the one done in February (it's NOT considered best practice to give the same test more often than six to twelve months). It was a brilliant report.

Five minutes after I'm done, my boss calls me into her office and says she got an email with more information about recent policy changes from certain Medicaid providers, one of which is my patient's. She knew I had already tested but explained they probably were not going to renew the authorization unless I gave him the exact test I gave in February. She asked me not to kill her when I told her I'd just finished the report. I will ask him not to kill me when we have to test again next week.

So what exactly is the point of this? He's not going to show progress after 9 sessions on a standardized test. If that's the only thing they're looking at, they will ignore the progress I stated toward specific treatment goals and deny therapy anyway. Or just for fun, they'll only authorize three months and we'll have to test again in August. Hell, by that time he might have the test memorized and score normal. I'll have "cured him!"