Medi-Cal faces delay in treatment approvals

Pharmacists, medical equipment suppliers and senior-care providers say delays in Medi-Cal treatment approvals are causing hardships for them and their patients.

Treatment approval requests that used to take a few days can now take weeks to be authorized by the state department that manages Medi-Cal.

The result: Providers are sometimes tending to patients and doling out drugs and equipment for free – hoping they will be reimbursed later, but with no guarantees.

Compounding the problem is a 10 percent cut in Medi-Cal reimbursement that takes effect July 1. There is also an expected one-month delay in reimbursements this summer.

"These are all impinging on Medi-Cal providers already struggling to keep their doors open," said Lydia Missaelides, executive director of the California Association for Adult Day Services.

State officials acknowledged approval backlogs at some field offices in recent weeks.

"We don't like having delays," said Stan Rosenstein, chief deputy director of the Department of Health Care Services. "We have an obligation to do the best we can to manage this workload with the resources we have."

The problem is bad enough that some patients are being declined services – particularly getting some prescription drugs – because required authorizations have not yet been received.

Although most Medi-Cal prescriptions do not require prior authorization, approvals generally are needed for patients prescribed six or more drugs or narcotic medications.

Marin County pharmacist Paul Lofholm, president of the California Pharmacists Association, said some drug authorizations are taking up to three weeks.

"If we don't have authorization and we don't know whether we are going to get it, we either give the patient the medicine or they don't get it at all."

Unless it's a life-or-death case, he said, many pharmacists opt against filling the prescription to avoid financial risk.

That's what happened to David Jaspers of Auburn, who relies on oxygen and drugs for chronic obstructive pulmonary disease and on narcotics for bone spurs in his neck and shoulders.

When he went to his pharmacy to pick up prescription refills recently, "(the pharmacist) said they are not cutting through the (approvals) right now," said Jaspers, 56.

After a few days without breathing medicine, Jaspers said he was hospitalized.

For his back and neck pain, Jaspers went three weeks with the few remaining pills he had, taking a much lower dose than was prescribed.

"I had no energy," he said. "I was sweating a lot, and my muscles were aching more than usual."

Jaspers' doctor, Holly Leeds, said she is frustrated.

"When I have a patient on narcotic medications and a lack of them is likely to result in withdrawal symptoms that may land him in the hospital, it's bad medical care," she said. "It's bad medical care that I am not responsible for."

Rosenstein said Medi-Cal tries to approve every treatment request within a day, but acknowledged there have been delays of up to 10 days. He cited a high demand for services.

"We have not had a reduction in our work force, but we haven't had an increase, and our volume is up," he said. "Medi-Cal is a growing program."

He added that when a doctor or pharmacist identifies an emergency, a prescription can be provided without prior authorization.

Dawn Myers Purkey runs the Yolo Adult Day Health Center in Woodland, where about 75 percent of participants rely on Medi-Cal. The program submits as many as 12 treatment requests each month.

New approvals for each participant's care are required every six months. Until recently, she said, they were being approved electronically in as little as 24 hours.

"Yesterday, we were told it would take 30 to 45 days for approval," Purkey said.

The result, she said, is that participants are allowed to continue to receive services under the assumption they will be approved. If Medi-Cal later decides to reduce the number of approved days or deny services altogether, the provider pays.

"During that time, the adult day health center is quite exposed because if you don't win the argument, you can't bill for anything that hasn't been approved," Purkey said.

Rosenstein said that by law, the state has 30 days to approve or deny a request for adult day health care. He said the Sacramento field office did get behind in approvals, and that several nurses have been temporarily reassigned from other offices to address the problem.

"It may take a little time to get caught up," he said.

The same is true for the backlog in approvals of oxygen for patients like Jaspers who have chronic lung ailments. Those delays are due to the March 7 closure of the Fresno Medi-Cal field office, Rosenstein said.

Meanwhile, Missaelides said, Medi-Cal providers are trying to figure out how they will cope with looming Medi-Cal rate cuts, and "keep doing the same work, serving the same people under the same rules."

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