Home health nurse struggles with state over services
A North Platte nurse who runs a home health business vows she won’t be quiet about her frustration over difficulties she’s having with the Nebraska Department of Health and Human Services.
Christine Sommer, owner of All aBout Caring In-Home Services Inc., has written letters and made phone calls to department officials, governors, senators and the state’s ombudsman. She’s written letters to North Platte and Lincoln newspaper editors.
She wants everyone to know Health and Human Serices is making it difficult for her to do her job and for people in the North Platte area to get health services they need.
Sommer said she has had multiple problems with Medicaid reimbursements, especially in the past year. They include: difficulty receiving payment for the services she provides, having payments denied, not getting reimbursement authorizations in a timely manner, finding out the department lost her authorization requests and getting late payments.
The department has peppered her with requests for additional information, she said, including questions about why a blind woman with cerebral palsy who lives alone requires three visits a day from a home health aide.
Sommer says she believes some Medicaid workers are becoming increasingly less cooperative, denying payments for numerous clients, or not sending authorization back at all, preventing Sommer from being able to bill within the allotted time frame.
Between Jan. 1 and Sept. 19 this year, department paid more than 6 million Medicaid claims. At the same time, the department handled 350 appeals from 150 providers for denials, according to spokeswoman Marla Augustine. No appeals were filed by home health providers.
Providers must justify need
Vivianne Chaumont, director of the Division of Medicaid and Long Term Care, which includes the Medicaid program, said Sommer seems to feel that she’s the expert in deciding whether someone needs home health service and that the department should trust her.
“No insurance company works that way,” Chaumont said. “You have to meet the rules.”
Chaumont did say the department had had some difficulties in the past in pre-authorizing services in a timely manner.
Sommer says Blue Cross Blue Shield, for example, responds verbally within 24 hours of such a request. The state takes an average of 10 to 15 working days.
Kathie Osterman, HHS spokeswoman, said the state uses a manual system and gets about 50 authorization requests a day.
The state likely will automate that system in the next four years, she said.
Chaumont said providers are required to justify the medical need for a service, whether it is provided by a more expensive RN or a home health aide, as well as the number of times the service is provided.
Payment for epileptic
HHS challenged Medicaid payment for home health service for All aBout Caring client Opal Feeney’s 20-year-old son, who has a severe form of epilepsy, Sommer said. His seizures, which occur daily, sometimes cause him to stop breathing.
Feeney said her son was not mobile, didn’t speak or feed himself and wears diapers. Because of his behavior and seizures, she said, he is disruptive at school and the district has hired someone to work with him at home.
Feeney said her son needs the home health services because it is so hard to find a permanent caretaker for him. Without help, she would not be able to keep her job as a hospital scrub nurse, she said. Then she would need even more assistance.
Her son needs someone to get him up in the morning, give him his medications and, when needed, administer special medications and oxygen to stop his grand mal seizures.
In another case, Sommer said, the state denied a client who has uncontrolled, almost continuous seizures and who had no one to care for her during the day. The state, she said, says the care provided by Sommer’s business was medically unnecessary.
Sommer said she complies with Medicaid regulations.
“We do not attempt, nor do we condone, Medicaid fraud,” she said. “However, I do need to be paid for the services we render and do not feel that I need to explain to some RN looking at one or two sheets of paper that my clients actually require our services.”
Chaumont gave her own example of a recent request by Sommer for nine skilled nursing visits to check the weight of a premature infant, without justification as to why it needs to be checked by a nurse, no doctor’s request for the visits and no explanation why the parent can’t take the baby to a physician’s office to be weighed.
Without sufficient information, the department denied the request.
Sommer, who has a bachelor of science degree in nursing from the University of Nebraska College of Medicine, started her agency in 2000 and was Medicaid certified in February 2003.
She has about 45 clients, most of whom have incomes at or below the poverty level, she said.
Sommer contacted U.S. Sen. Chuck Hagel’s office about the denial of handicapped children, and she said she believed the state was retaliating against her for that.
She also has contacted Attorney General Jon Bruning, Gov. Dave Heineman and various other officials.
“I will not stop,” she said. “I will take this as far as necessary. … I feel strongly that I must be paid for the care I provide for Medicaid individuals, as well as any other clients I see.
Both try to do right
Sommer has had trouble with Medicaid off and on since 2005, she said, when HHS staff members who were more cooperative and collaborative in working with her agency were replaced. When that has happened, she has complained.
“Mr. Heineman,” she said in a 2006 e-mail, “I have huge concerns about a breakdown in reporting and obtaining necessary services in this area if we continue to lose those workers who are willing to exceed expectations to provide to provide for the best interests of vulnerable adults.”
In early July, she met with Chaumont and Cindy Kadavy, unit manager for long-term care, which includes home health care. A representative from the ombudsman’s office came along.
A letter sent to Sommer after the meeting by Christine Peterson, HHS chief executive officer, said the department had developed a plan to respond to her pending authorization requests.
Peterson said Medicaid providers have the option of appealing any denial.
Julie Pham, assistant ombudsman who went along on the July visit, said the issue revolves around Sommer trying to meet the need for more services in her area of the state.
“She is sometimes the last option, and she can’t turn them down. She feels responsible,” Pham said. “And DHHS is saying they have to follow the guidelines.”
Reach JoAnne Young at 473-7228 or jyoung@journalstar.com.
Christine Sommer, owner of All aBout Caring In-Home Services Inc., has written letters and made phone calls to department officials, governors, senators and the state’s ombudsman. She’s written letters to North Platte and Lincoln newspaper editors.
She wants everyone to know Health and Human Serices is making it difficult for her to do her job and for people in the North Platte area to get health services they need.
Sommer said she has had multiple problems with Medicaid reimbursements, especially in the past year. They include: difficulty receiving payment for the services she provides, having payments denied, not getting reimbursement authorizations in a timely manner, finding out the department lost her authorization requests and getting late payments.
The department has peppered her with requests for additional information, she said, including questions about why a blind woman with cerebral palsy who lives alone requires three visits a day from a home health aide.
Sommer says she believes some Medicaid workers are becoming increasingly less cooperative, denying payments for numerous clients, or not sending authorization back at all, preventing Sommer from being able to bill within the allotted time frame.
Between Jan. 1 and Sept. 19 this year, department paid more than 6 million Medicaid claims. At the same time, the department handled 350 appeals from 150 providers for denials, according to spokeswoman Marla Augustine. No appeals were filed by home health providers.
Providers must justify need
Vivianne Chaumont, director of the Division of Medicaid and Long Term Care, which includes the Medicaid program, said Sommer seems to feel that she’s the expert in deciding whether someone needs home health service and that the department should trust her.
“No insurance company works that way,” Chaumont said. “You have to meet the rules.”
Chaumont did say the department had had some difficulties in the past in pre-authorizing services in a timely manner.
Sommer says Blue Cross Blue Shield, for example, responds verbally within 24 hours of such a request. The state takes an average of 10 to 15 working days.
Kathie Osterman, HHS spokeswoman, said the state uses a manual system and gets about 50 authorization requests a day.
The state likely will automate that system in the next four years, she said.
Chaumont said providers are required to justify the medical need for a service, whether it is provided by a more expensive RN or a home health aide, as well as the number of times the service is provided.
Payment for epileptic
HHS challenged Medicaid payment for home health service for All aBout Caring client Opal Feeney’s 20-year-old son, who has a severe form of epilepsy, Sommer said. His seizures, which occur daily, sometimes cause him to stop breathing.
Feeney said her son was not mobile, didn’t speak or feed himself and wears diapers. Because of his behavior and seizures, she said, he is disruptive at school and the district has hired someone to work with him at home.
Feeney said her son needs the home health services because it is so hard to find a permanent caretaker for him. Without help, she would not be able to keep her job as a hospital scrub nurse, she said. Then she would need even more assistance.
Her son needs someone to get him up in the morning, give him his medications and, when needed, administer special medications and oxygen to stop his grand mal seizures.
In another case, Sommer said, the state denied a client who has uncontrolled, almost continuous seizures and who had no one to care for her during the day. The state, she said, says the care provided by Sommer’s business was medically unnecessary.
Sommer said she complies with Medicaid regulations.
“We do not attempt, nor do we condone, Medicaid fraud,” she said. “However, I do need to be paid for the services we render and do not feel that I need to explain to some RN looking at one or two sheets of paper that my clients actually require our services.”
Chaumont gave her own example of a recent request by Sommer for nine skilled nursing visits to check the weight of a premature infant, without justification as to why it needs to be checked by a nurse, no doctor’s request for the visits and no explanation why the parent can’t take the baby to a physician’s office to be weighed.
Without sufficient information, the department denied the request.
Sommer, who has a bachelor of science degree in nursing from the University of Nebraska College of Medicine, started her agency in 2000 and was Medicaid certified in February 2003.
She has about 45 clients, most of whom have incomes at or below the poverty level, she said.
Sommer contacted U.S. Sen. Chuck Hagel’s office about the denial of handicapped children, and she said she believed the state was retaliating against her for that.
She also has contacted Attorney General Jon Bruning, Gov. Dave Heineman and various other officials.
“I will not stop,” she said. “I will take this as far as necessary. … I feel strongly that I must be paid for the care I provide for Medicaid individuals, as well as any other clients I see.
Both try to do right
Sommer has had trouble with Medicaid off and on since 2005, she said, when HHS staff members who were more cooperative and collaborative in working with her agency were replaced. When that has happened, she has complained.
“Mr. Heineman,” she said in a 2006 e-mail, “I have huge concerns about a breakdown in reporting and obtaining necessary services in this area if we continue to lose those workers who are willing to exceed expectations to provide to provide for the best interests of vulnerable adults.”
In early July, she met with Chaumont and Cindy Kadavy, unit manager for long-term care, which includes home health care. A representative from the ombudsman’s office came along.
A letter sent to Sommer after the meeting by Christine Peterson, HHS chief executive officer, said the department had developed a plan to respond to her pending authorization requests.
Peterson said Medicaid providers have the option of appealing any denial.
Julie Pham, assistant ombudsman who went along on the July visit, said the issue revolves around Sommer trying to meet the need for more services in her area of the state.
“She is sometimes the last option, and she can’t turn them down. She feels responsible,” Pham said. “And DHHS is saying they have to follow the guidelines.”
Reach JoAnne Young at 473-7228 or jyoung@journalstar.com.
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