Posted on 08/01/2002 1:12:11 PM PDT by cva66snipe
Tennessee Freepers I'm asking for help. Not money please {and I really mean that} but letters, E-mail, and phone calls to agencies and officals that run Tenn Care and one of it's HMO's. Some of you who know me know my wife as well as myself are disabled. The issue here is medical care being denied my wife that would be given to others not disabled.
Tenn Care about 10 years ago took over our Medicaid system. Most of us remember how it was done and the kaos it has brought upon us. Medicaid was intended for medical coverage to workers who illness became disabled and no longer able to work again. This happened to my wife in 1985. We think it was a result of a Spinal Stroke due to Polio Relapse Syndrome. She is a quadriplegic. Limited use of hands and arms no leg functions.
During this time I have been her caregiver I married her understanding this situation. We recieve no outside agency help in her day to day care and other functions that some of it in a nursing home would require an RN. In short I believe in as much as possible take care of your own.
She needs sooner rather than later a full mouth tooth extraction and it must be done in an operating room in the hospital by an Oral Surgeon. A previous dentist doing an extraction made a near fatal medication judgement. She has taken heart medications for 16 years as well. This added to her limited abilities has led to the teeth problem. Below is a letter I have sent to a local news paper. After reading it I think you can understand better where I'm coming from. Following the letter I will list as much information as possible as to agencies and officals as well as a way to identify her. I would rather not publish her name but Free mail me and I will gladly give that information as well as proof of this situation. Here's the lettter:
Editor:
About 10 years ago this state saw fit to end portions of the Medicaid program which included the coverage for the disabled worker. A new and so called improved program born of scandal and down right black mail upon the medical community was born called Tenn Care. Persons who worked and had become disabled were put into a HMO type system. These are persons needing consistent and extended medical attention. The doctors know the patients needs and are extremely careful in their judgments in this care.
As time went along Tenn Cares HMO's each year were relieved of more and more responsibilities of coverage especially to those disabled who after 2 years disability become Medicare eligible as well. Medicaid was providing a co-payment to primary care physicians which made it possible for doctors to absorb the cost. Tenn Care HMO's are now not required to do so. But the doctors as well can not bill a Medicare patient for that payment if they are on Tenn Care. Doctors are being made to take substantial cuts in pay to treat disabled citizens in this state. I've seen the Medicare statements it's pathetic what a doctor ends up being paid. Most any other profession would not tolerate it.
So what are they to do? The doctors are now being forced by economics to not take on Medicare/ Tenn Care patients. Don't believe me? Try calling any doctors office and say you are disabled on Tenn Care and Medicare. Last year we went through nearly 6 months without primary care. Some medications were not taken as prescriptions had expired. The doctors practice owned by a hospital as a cost measure was closed. The doctor got re-established and luckily took us back. Many more disabled are not this fortunate.
Now for the intent of this letter. My wife is a quadriplegic and needs immediate extensive tooth extraction's. It is a medical necessity soon to be a medical crisis. We saw an Oral Surgeon last November who agreed to do the extraction's but had legitimate medical concerns he wanted addressed first due to her medical history. A prudent move I think anyone would say is justified. The testing was done and this took us into 2002 which brought a rule change in Tenn Care it seems. Up till this date the Oral Surgeons word was sufficient to justify need no referrals needed. We now find out her General Practitioner must say it is a necessity that has been done as well.
We jump through hoops and what happens? Tenn Care denies coverage on the basis of it not being medically necessary. We appeal and ask for a hearing before a judge which is supposed to be a Right in the appeals process. Now without even seeing the judge or having any form of appeal the matter is dismissed by Tenn Care saying Medicare pays for Dental Care. Medicare indeed does not. Tenn Care states they only pay for medications. Tenn Care says Medicare is responsible Medicare says Tenn Care is. As far as I know no one in this state oversees Tenn Care except Tenn care. They answer to no one not even the lawmakers as far as that goes.
But a person who is reasonably healthy and on Tenn Care due to income limitations and not being offered insurance at work gets better coverage that those in medical need and can get a doctor or if medical necessity tooth extraction's because Tenn Care pays for those services for them. They pay their doctors more than a Medicare patient's doctor receives for a Medicare/ Tenn Care disabled patient. Now I'm not one who likes to push such programs as Americans with Disabilities Act. Actually I'm not in support of Universal Health Care as it is a burden placed upon the taxpayer it is Socialized Medicine.
However I myself am disabled also. Both of us paid a portion of our wages we earned into Social Security and Disability Insurance. Which was the former Medicaid intent our lawmakers have lost any sight of. It was our Disability medical benefits this state has stolen to fund Tenn care and I want to be treated no less an equal that someone who never paid a cent getting premium care is getting on my dollar. Am I being unreasonable? So here is what is going to happen. This will soon be a life threatening medical crisis. Common sense says as much. Bad teeth lead to blood poison. It will become an acute medical crisis and she will be taken to a local Emergency Room where rather than a simple day surgery in and out preventive care procedure being done, she will likely be hospitalized for a week or more being pumped full of high dollar anti- biotic and the teeth extracted at that time.
I am one who supports the immediate abolishment of Tenn Care at least in regards to the disabled. We do not belong in such a reckless and unaccountable program and should be able to have our care overseen by the State Inspector Generals Office. This was the case up till the time Medicaid was deliberately made to fail. They honorably and fairly performed this function. We are former health care industry workers so we know what happened and what we lost. I here by in a public forum accuse Tenn Care and the State Lawmakers who support it of operating it in a fraudualant manner. The disabled workers have been robbed. I accues the Lawmakers who support Tenn Care of gross discrimination and prejudice toward the disabled workers who paid for services that are not being rendered. Those who don't support it have my respect ,and mine and families vote.
End of letter
PHP or Preferred Health Partnership which is the HMO involved. Phone number is 1-800-747-0008 in Knoxville it is 470-7440. Their address is PHP Tenn Care 1420 Centerpoint BLVD Knoxville, Tennessee 37932
As well my state Senator is Randy McNally-R E-mail address is sen.randy.mcnally@legislature.state.tn.us
The Tenn Care over site committee members are Chairman Rep Gene Caldwell E-mail address caldwell@tennesseeweb.com 202A War Memorial Building Nashville, TN 37243-0133 Phone (615) 741-4400 Staff Contact: Betty Faye Lewis
Senator Doug Jackson E-mail address sen.doug.jackson@legislature.state.tn.us
11A Legislative Plaza Nashville, TN 37243-0025 Phone (615) 741-4499 Fax (615) 741-4324 Staff Contacts: Stacy Karbowiak
LINCOLN DAVIS E-mail address sen.lincoln.davis@legislature.state.tn.us
6-A Legislative Plaza Nashville, TN 37243-0212 Phone (615) 741-1449 Fax (615) 741-3308 Staff Contact: Sammy Lowdermilk
These are the ones who are supposed to be Chairman, Co-chairman , and Secretary of the Tenn Care Oversight.
There is a toll free number into the Tennessee Legislature but I can't locate it right now. We are residents of Anderson County, Tn. The town is called Heiskell.
Like I said I don't want money. This is about principle and government fraud and corruption. It is about treating prisoners in this state better than the disabled who paid hard earned dollars for a service we prayed to never have to use. In her case it was catastrophic illness she was hospitalized for 6 months in 1985. No one in this forum could have covered that expense. Our company gave us health care insurance. Once your sick days are used up 30 days later health care insurance is dropped as well. This isn't welfare It's your's and our money the government is using to try and socialize health care with. Thanks for the help and efforts in advance. If this post looks out of sorts I'm sorry. I'm at the literal end of my rope {it's agrivating my own health situation} and feel only pressure from such as "we the peoples outrage" will bring results. I spent well over 2 hours today on being given a run around. This has been an ongoing problem. Someone's lying and I know who it is. Tenn Care! Thanks, CVA66SNIPE
Thanks JR for permission.
Sadly, this is not surprising. Good luck.
I know a healthy person on Tenn Care who had impacted teeth and had them taken out with no problem. But the person is not on Tenn Care through disability nor a Medicare patient. It is a lack of employer provided insurance that got him on Tenn Care. It's the Medicare patients Tenn Care has by our lawmakers it seems been relieved of paying any claims but medication. IOW in most cases Tenn Care HMO's are making a mint off of us as the drugs are generic.
Ignorance Making You Ill? Cure It!
...to find piles of contact information. That "conservative megalinks" link can easily reach a lot of state-level government people.
Well I hope Van Hilleary & Bryant won the GOP primary tonight. I hope Lee Franks and Mead won the state GOP nominations. I want those other sorry pathetic money grabbing HMO shills out of office. I hope they have the guts to end Tenn Care restore Medicaid to the limited intent and accountability. That would solve the health care crisis and state budget crisis in one stroke of the pen. They can use tax break encintives so person working or their employers on a voluntary basis can afford to buy reasonable health care insurance.
We appeal and ask for a hearing before a judge which is supposed to be a Right in the appeals process. Now without even seeing the judge or having any form of appeal the matter is dismissed by Tenn Care saying Medicare pays for Dental Care.
Did TennCare cancel your hearing before it got to a judge?
From what I am reading, they aren't supposed to do that. It is your right to appeal and to get a decision from an independent judge.
Have you called TennCareSolutions at 1-800-978-3192?
We appeal and ask for a hearing before a judge which is supposed to be a Right in the appeals process. Now without even seeing the judge or having any form of appeal the matter is dismissed by Tenn Care saying Medicare pays for Dental Care.
Did TennCare cancel your hearing before it got to a judge?
From what I am reading, they aren't supposed to do that. It is your right to appeal and to get a decision from an independent judge.
Have you called TennCareSolutions at 1-800-978-3192?
I trying to get the Oak Ridger to look into the bias angle of it. In a Dem town that's about as good as I can hope for. Then I can say what I said here as a solution :>} I'm not asking for anymore that what we paid for. If they can use that funding to pull the teeth of others they can for her as well. I can understand prior approval ect to justify necessity. But when that is produced then the treatment should be approved. They changed the rules after we played by them.
Looks like Tenn Care McNally got back in. Well maybe there's still hope on Caldwells old seat in the Reps. Hilleary will have to put blinders, bridle, and bit, on McNally to get a conservative bill past him.
That's what happened and I called them and they've called me twice. They refered me to Medicare. Medicare only pulls teeth for tumors or in preperation for chemo treatment in some cases. However PHP the Tenn Care HMO plainly states that adult dental care can be provided based on medical necessity with prior approval. They tossed the appeal {usual procedure} which was over the phone said too bad and call Medicare. They stated Tenn Care will only pay for her medication.
If that is true they are in a litteral gold mine. Medicare takes all their risk except medication on the disabled. Her meds would be about $50 a month tops mine about $70 probably a lot less on their cost as it is a formulary list they go by.
There's a lot of things Tenn Care isn't supposed to do and gets away with because enough of our lawmaker are in their pocket to shut it up. Lawmakers will play dumb when confronted with Tenn Care issues.
I might have to but the paper worked once before. When they were setting Medicaid up for the fall the state stopped paying providers. Equipment providers started asking for money up front and a promise that we would get re-imbursed from Medicaid. Medicaid did not work like that. An article was published and problem was solved. That was about 11 years ago more or less.
There's no doubt in my mind Medicaid was purposely destroyed or made to fail in Tennessee. I find it rather odd that the new head honcho of Tenn Care was Gov. Ned Rays man running Health & Human Services. Manny Martins was in the McWherter administration I remember it. Matter of fact here it is,
http://www.state.tn.us/commerce/pressr3.htm
For Immediate Release September 14, 2000
MANNY MARTINS APPOINTED DEPUTY COMMISSIONER FOR TENNCARE REGULATORY ARM
Nashville -- Tennessee Department of Commerce and Insurance (TDCI) Commissioner Anne Pope today announced the appointment of public health professional Manny Martins as deputy commissioner of TDCI in charge of TennCare regulation. The division is charged by statute with regulating and monitoring HMOs and BHOs that participate in TennCare, the state's $4.3 billion health care program for people who are Medicaid eligible, uninsured or uninsurable.
"In practical terms," said Pope, "two of our Department's primary responsibilities as regulator are monitoring whether HMOs and BHOs have enough money to pay the doctors and hospitals and monitoring whether those providers are being paid correctly. Mr. Martins understands the role of this Department as regulator. We believe his experience will provide a strong compliment to the work of John Tighe and Mark Reynolds in their administration of the TennCare program."
"I am looking forward to working for Commissioner Pope, who is providing new and dynamic leadership to Commerce and Insurance, and with the very capable staff of the department and TennCare," said Martins. "Accurate and timely payment to providers must be achieved for TennCare to work properly and we are committed to accomplishing that objective."
Since May 1999, Martins has served as special deputy rehabilitator for the third largest TennCare HMO, Xantus Healthcare of Tennessee (XHT). As rehabilitator, Martins has maintained XHT as a viable medical services provider for approximately 150,000 TennCare enrollees, stabilized and expanded its provider network and significantly improved operations. Under Martins' leadership, the administrative costs of XHT have been reduced from 15% of revenue at the time the company was placed into rehabilitation to about 9% of revenue. During his tenure as Special Deputy, Martins has had extensive involvement with both TennCare enrollees and the provider community.
"I believe Mr. Martins' assistance will be invaluable as we work through regulatory issues with the existing TennCare HMOs and as new HMOs enter the TennCare program," said Pope. "Mr. Martins understands TennCare and brings us a unique hands-on perspective with healthcare experience in public health, the private sector and having successfully operated a TennCare HMO."
"I am very pleased that Mr. Martins accepted the regulatory position with Commerce and Insurance," said John Tighe, Deputy Commissioner of Finance and Administration. "I agree with Commissioner Pope that Mr. Martins' experience in managing a TennCare HMO will provide real, practical insight into how best to regulate these entities. Solid regulatory oversight by Commerce and Insurance is critical to the ultimate success of TennCare."
Martins began his public service in Tennessee over 30 years ago. In 1987, after overseeing the operations of Tennessee's 95 County Health Departments for nearly ten years, Martins became Assistant Commissioner for Medicaid. In 1994, he was appointed as the first Assistant Commissioner for TennCare, serving in that capacity under both Governors McWherter and Sundquist. He served as Executive Vice Chancellor for the University of Tennessee/Center for Health Sciences from 1995 until he returned to the private sector in 1998.
Martins will begin work as TDCI deputy commissioner in charge of TennCare regulation October 2, 2000. As Deputy Commissioner, Martins will report to TDCI Commissioner Pope. Martins' successor as special deputy rehabilitator for XHT will be named shortly.
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