MaineCare's Prior Authorization Policies: Sometimes Government Cuts Are Not the Reason Your Medical Supplies Were Denied
By Mike Reynolds


With the rash of budget cuts and other rumblings heard around Augusta, I wasn’t completely surprised to find I had to go through a prior authorization review regarding the products I use to manage my incontinence. I had surgery this past year and now have a colostomy, an opening in the abdomen through which the intestine empties waste into a bag attached to the skin. In addition to the colostomy, I use disposable adult briefs. Since incontinence is a fairly common issue for adults with cerebral palsy, I figured the only problem I’d have during the review would be justifying the rather specific brands of products I use. Given my well-documented history of skin reactions to other products, I figured I'd be all set.

Of course, dealing with a state entity is never easy. A few things you should know before going any further: I have both MaineCare, a state-based, partially state-funded Medicaid program, and Medicare, because I worked for a few years after college. I have since learned that Medicare pays for all of my colostomy supplies, but MaineCare pays for all my other incontinence-related supplies: briefs, chux (disposable protective pads), catheters, etc. These items, along with other equipment like wheelchairs, grab bars, and walkers, are all collectively known as “Durable Medical Equipment” (DME) in the world of insurance and prior authorizations. For DME, the dealer you are getting the supplies from will usually get the information needed from your doctor and send it off to get the prior authorization process started. If you need prior authorization for a medication, the process is quite different; your doctor’s office will initiate the request.

Your rights as a client of MaineCare, as well as other Medicaid programs, are kind of limited until your claim is either deferred or denied. It can take up to 30 days to get a deferral if the independent medical company needs more information. Your claim can be deferred for something as minor as a form’s not having information in the right section. My claim was deferred and the problem was quite vexing; my doctor’s staff could not for the life of them figure out what the independent medical company wanted. Further complicating this was the fact that that I could not call the same folks that my doctor or my DME provider was talking to; they would not talk to me, as it was not their job to talk to patients. I was able to speak to the nurse who reviewed my case. He answered his phone once, pulled up the letter he sent me, and tried to read it to me, but he wouldn't explain exactly what the letter meant. He then stopped answering his phone and went on vacation. A second nurse finally requested the information the independent medical company needed from my doctor. Luckily, my doctor's office had all the information that was requested; had they not had it, I would have had to start the entire review process again. The information was faxed to the second nurse within the hour. However, she didn't answer her phone or return voicemails once the documents were faxed. It took a third nurse to review the information and realize that someone had mistakenly written that I had a urostomy instead of a colostomy --- a urostomy is an artificial opening made to prevent drainage of urine through the bladder. The third nurse and I agreed it was an annoying mix-up, and my claim was eventually approved.

If your medical claim is denied, there is help through the Disability Rights Center, but the center can't help you until you actually receive a denial. You might need to wait a bit to get an appointment with the DRC, but they have some of the best advocates in Maine on staff and are well worth the wait. For more information on the DRC, visit www.drcme.org.


Michael  Reynolds is a writer who lives in Lewiston and has been diagnosed with Cerebral Palsy at birth.

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