Iowa Medicaid company forced to provide special wheelchairs to disabled clients

Jason Clayworth | The Des Moines Register

Show Caption Hide Caption Iowa's privatized Medicaid program About 600,000 poor or disabled Iowans have their health care covered by Medicaid, which has been managed by for-profit companies since 2016.

A Medicaid company must pay for specialized wheelchair equipment it denied to disabled clients after losing three simultaneous court battles challenging whether Iowa can force it to provide health services.

The appeals by UnitedHealthcare — each involving a severely disabled Iowan who can't walk independently — lingered for more than a year while the managed care provider denied doctor and state orders that it pay for the specialized equipment.

In each case, UnitedHealthcare took an unusual step: After the directors of the Iowa Department of Human Services sided with the patients, the company filed litigation in district court challenging the state’s authority as the final arbitrator.

Some of the litigation lasted more than 18 months.

Neither Human Services nor UnitedHealthcare would say whether two of the three disabled clients who were part of the lawsuits went without the wheelchair equipment during the appeals.

In the third case, the family of Spencer nursing home resident Ann Carrigan said she was able to avoid a 15-month wait for a special wheelchair through Midwest Respiratory Care after the Nebraska company provided the equipment without knowing whether it would be reimbursed by UnitedHealthcare.

UnitedHealthcare is one of two companies managing the state’s $5 billion Medicaid program, which provides care for 600,000 poor and disabled Iowans. It and Amerigroup are paid up to 12 percent of the program's annual costs — $600 million — for its management services.

Ken Sander, an official with Midwest Respiratory Care, warned this week that problems with Iowa Medicaid appeals persist.

He referenced a Des Moines Register investigation published earlier this year that found multiple cases where Medicaid patients were denied due process and in-home care. The investigation also identified what Iowa’s Long-Term Care Ombudsman described as a “systemic” cycle of denials.

“It’s very disappointing,” Sander said of the continuing equipment denials. “It’s pretty much standard across the board. They’re denying everything.”

UnitedHealthcare won’t challenge court rulings

UnitedHealthcare declined an interview, but spokesman Garrett Kasper said in a statement the company has no plans to seek a further review.

“We encourage members to exercise their right to appeal whenever they feel it is appropriate, as the appeals process is a critical component of an effective coordinated care program,” Kasper said.

For decades, Iowa’s Human Services managed the state’s Medicaid program at a management cost of 4 to 8 percent.

In 2016, Gov. Terry Branstad pushed to hire for-profit companies to manage the program, saying it would save the state money and improve services.

To date, those goals have remained elusive as money and problems with services continue to make headlines. In June, state Medicaid Director Mike Randol estimated that Iowa saved about $140.9 million, but the state has had difficulty explaining how it arrived at that figure.

Critic calls for sanctions against UnitedHealthcare

UnitedHealthcare’s effort to defy the state’s final orders raises questions about the program’s oversight and should be the subject of Human Services sanctions or the cancellation of the company’s Medicaid contract, said Sen. Pam Jochum, D-Dubuque, a privatized Medicaid critic whose grown daughter is disabled and uses the program.

"'Ruthless' is the one word I hear every (healthcare) provider say about UnitedHealthcare,” Jochum said. “It just blows me away.”

But Sen. Charles Schneider, R-West Des Moines, said he believes the final resolution in the court cases demonstrates that at least part of the Medicaid system of checks and balances worked.

“I think it’s a sign that there’s proper oversight in place,” Schneider said. “The fact that the director of DHS can make a final determination like that and rule in favor of the patient is a good thing.”

Although it’s not uncommon for state contractors or bidders to appeal Human Services' decisions, the three cases marked the first time a private company challenged the agency’s authority to render final decisions in the Medicaid program, agency spokesman Matt Highland said.

“The process worked as it should,” Highland said.

The cases

Special wheelchair to prevent choking of nursing home resident denied

The client: Ann Carrigan, a 70-year-old woman from Spencer in a nursing home, has cerebral palsy and a brain injury from a vehicle accident.

The Medicaid issue: UnitedHealthcare denied a wheelchair customized to help Carrigan sit so that she wouldn't choke or fall out.

The denial: A standard wheelchair would meet Carrigan’s needs, according to a Dec. 5, 2016, denial authored by Dr. Walter Bradley of United.

The ruling: Federal and state rules say the prescribed chair is covered under Medicaid, Iowa Administrative Law Judge Forrest Guddall ruled April 4, 2017.

The appeal: UnitedHealthcare appealed to Human Services. Chuck Palmer, the department's director, sided with Carrigan in a decision issued June 13, 2017.

District court: UnitedHealthcare challenged Palmer’s decision-making power. Polk County District Judge David May concluded on July 3, 2018, that the company is subordinate to Human Services' final decision.

Lightweight wheelchair required for woman’s mobility denied

The client: Mildred Baker, a 70-year-old woman in an Oakland nursing home, has multiple health issues that have left her unable to walk independently.

The Medicaid issue: UnitedHealthcare denied a customized wheelchair designed to be lighter in weight with additional functions.

The denial: The wheelchair customization could be met with a standard chair, according to a Feb. 28, 2017, denial authored by Dr. Gale Browning of United.

The ruling: The reasons given by UnitedHealthcare to deny the chair are not supported by medical records, Iowa Administrative Law Judge Christie Scace ruled April 21, 2017.

District court: UnitedHealthcare challenged Palmer’s final decision-making power but lost. Polk County District Court Judge Eliza Ovrom upheld Palmer's authority in a March 14, 2018 decision.

Wheelchair ramp is too costly