Hassles with reimbursement, low rates, conflicting requirements are forcing some providers to stop taking Medicaid.
At least at the cellular level, cancer doesn’t discriminate by income. It strikes rich people and poor people and those in between, forcing new reckonings and leaving emotional and physical scars. October is Breast Cancer Awareness Month, but beneath all the pink-themed marketing is a new normal: Insurance coverage can dictate a woman’s recovery. But the new normal for a woman faced with losing a breast to cancer can be sadly dictated by her health coverage.
If your coverage is through Iowa’s Medicaid program for low-income people, you may find yourself unable to get a post-mastectomy breast prosthesis. That is, unless you can shell out up to $1,000 in cash.
Fittings Unlimited in Urbandale is one of a few local vendors of supplies related to post-mastectomy care. It has a sign in its store saying Medicaid payment is no longer accepted, so Medicaid patients must pay in cash. The sign went up in June and blames untimely reimbursements from the state’s recently privatized Medicaid system. It directs people to call the governor’s office with questions.
Joyce Sweeney, an administrative assistant at Fittings Unlimited, said the move was driven by the slow pace of reimbursements from the private companies enlisted by the state to administer Medicaid.
“We just can’t afford to do it because they just don’t pay,” she said, adding the store is owed between $8,000 and $9,000 in reimbursements dating back to last year.
A single breast prosthesis can cost between $350 and $500, Sweeney said. Before Medicaid privatization, “We did $90,000 to $100,000 in sales (to Medicaid recipients) per year with no problem.”
“It’s very sad for these patients,” she said.
Stacey’s Bra and Lingerie in Urbandale, which also sells post-mastectomy items, is seeing the same delay in reimbursements, according to owner Stacey Fox. And then,
“the reimbursement barely covers the costs I pay for the items so there is actually a loss when servicing these clients,” she wrote me in an email. A sales associate at the store said it doesn’t have many Medicaid patients, but Fox said, “We still provide this service as goodwill.”
In April 2016 three for-profit companies took over management of Iowa’s Medicaid program. Gov. Terry Branstad says the program is saving the state money but the companies say they are losing money. Critics worry about a loss of services.
Zach Boyden-Holmes/The Register
Matt Highland, a spokesman for the Iowa Department of Human Services, which manages the state’s Medicaid office, said, “Durable medical equipment is an area we continue to work on with MCOs and providers to resolve those issues, and we are told they’re improving.” MCOs are the three private managed care organizations the state has contracted with for Medicaid services.
Fittings Unlimited refers patients to NuCara Pharmacy in Pleasant Hill when they need custom-made equipment such as compression sleeves for lymphedema. That’s a swelling of the arms caused by the removal of lymph nodes during a mastectomy or lumpectomy. It can lead to an accumulation of lymph fluid, which can also happen in the hand, chest or back.
Meg Farris talks to a Tulane scientist who may have a breakthrough for people who have lost a nipple through mastectomy.
Jill Roberts is based at NuCara’s headquarters in Waterloo but does fittings one day a week at the Pleasant Hill and Nevada pharmacies. Roberts also said the reimbursements are either lower than expected or late to come. She said a custom-made lymphedema sleeve and hand set can cost $1,273 retail and must be replaced every six months. The items are approved for medical necessity, she said, But since Medicaid switched to MCOs, they have not been reimbursed because of “billing-code” issues.
If it’s frustrating for the pharmacy, imagine the frustration for patients. NuCara began providing custom-made mastectomy items in March, according to Jenny Brustkern, billing manager for NuCara in Waterloo, who said there have been problems getting paid ever since.
Until April 1, providers were required to follow Iowa Medicaid guidelines. But since the switch, Roberts said when she has sent in prior authorization requests, she is told to just bill them under the regular mastectomy code. But she said that doesn’t work if, for example, “the price allotted is $62 and it costs us $500 to have it made.”
“The MCOs have been horrible,” Roberts said. “Now we’re dealing with three managed care organizations and each one has different requirements. The left hand doesn’t know what the right hand is doing. The MCO tells us to bill a certain way but no other health insurer bills it that way.”
Indeed. You can see those different requirements for durable medical equipment on the DHS website.
Brustkern said she had a recent conversation with an AmeriHealth Caritas representative who suggested penciling a code onto the manufacturer’s suggested retail price sent in with claims, but other companies consider that tampering.
Medicaid covers some 600,000 Iowans. Since Iowa’s switch to private companies, we’ve heard of nursing homes dropping patients on ventilators because of low payment rates. We’ve heard of limits on medical providers authorized to accept Medicaid and of mental health centers that have not been reimbursed for patients on Medicaid.
Karen Muelhaupt, a breast cancer survivor, saw the sign at Fittings Unlimited when she went to replace her old breast prostheses, which cost $360 apiece. She has private insurance and Medicare so the change won’t affect her. But she followed the suggestion to write the governor’s office, asking in her letter, “Can you explain to me how a woman on Medicaid will have $720 for her breast prostheses? Not only has she gone through the trauma of cancer, disfiguring and emotional surgery, but now she must find funds to pay for prostheses! That does not even include the special bras that are required to hold the (silicone) form in place, ” which Muelhaupt says cost $45 apiece.
“What is your response to this?” she asked.
I’ll let you now when she hears back.
Rekha Basu is an opinion columnist for The Des Moines Register. Contact: firstname.lastname@example.org Follow her on Twitter @RekhaBasu and at Facebook.com/ColumnistRekha. Her book, “Finding Her Voice: A collection of Des Moines Register columns about women’s struggles and triumphs in the Midwest,” is available at ShopDMRegister.com/FindingHerVoice