By Representative Jesse Kremer
January 19, 2016, Kewaskum, Wisconsin

Throughout my first term in office, I have had the opportunity to participate as a member of the Assembly Health Committee. Over the past few weeks, the Committee has held hearings on administrative rules. After a law is passed, the state agency that oversees the program creates rules to comply with the new law. During one of these hearings, we had the opportunity to listen to disabled adults and parents of disabled children tell their stories concerning prior authorization for physical, occupational and speech therapy in the Medicaid program. When a person with a disability requires therapy, they must petition the Department of Health Services (DHS) as often as every three months, even if they are permanently disabled, have already gone through prior authorization and have been approved by their for-profit insurance carrier.

Issues with prior authorization were targeted during a DHS audit in 2001; however, the audit findings were never addressed. This is big government at its worst for a number of reasons. First of all, if the primary, for-profit carrier has already approved the therapy, then why waste tax dollars to go through the prior authorization process a second time at the state level? Second, when the state denies a claim, they are not required to specify exactly why the claim was denied. This wastes weeks and even months before an individual receives the therapy that they require. If an appeal is made, legal teams are usually required to prove the need for therapy, with hundreds of pages of accompanying paperwork. Finally, there often times are no qualified specialists at DHS to evaluate certain conditions, especially in children. In these cases, I will be requiring DHS to partner with outside therapists who are experts in their field. There are organizations that will provide these services at potentially little to no charge.

After listening to heartbreaking stories and realizing that this is a real problem, I began to work closely with the Wisconsin Physical Therapy Association, Wisconsin Occupational Therapy Association, Wisconsin Speech Therapy Association and Disability Rights Wisconsin immediately following the hearing. I would encourage anyone with a loved one who has experienced difficulty with Medicaid prior authorization to please contact my office and share your input and suggestions. This is an issue that I am actively researching and one that I would like to introduce immediately after the next election cycle.