HBOT as qualifier for Beckett

[Guest guest]

,

Beckett is just one of several Medicaid waiver programs.

In 2006, two weeks after a second hearing before the

same Administrative Law Judge (ALJ) who first heard our case in 2000,

we were notified by certified letter that our son Jimmy no longer

qualified for Medicaid under Beckett. The person who made the

decision was Dr. , a pediatric neurologist and medical

director of the Georgia Medical Care Foundation (GMCF). The GMCF is a

quasi-public agency created by CMS (Centers for Medicaid and Medicare

Services--formerly known as the Health Care Financing Administration

[HCFA]).

Medical decision making for Medicare recipients used to all be

performed by HCFA/CMS at the home office in Washington DC. As you can

imagine, this was a cumbersome and nightmarish process that could

take months or even years to make decisions. The solution--20 or 25

years ago a system/network of what HCFA/CMS called " Peer Review

Organizations " (PRO) were created by HCFA/CMS in each state to

perform medical-decision making tasks for Medicare patients in those

states.

A few years ago, HCFA/CMS decided the PROs could also be utilized to

improve the quality of healthcare for Medicare recipients, and now

the PROs are known as QIOs.

Georgia's QIO is the GMCF.

Because the Medicaid plans of most states are exact duplicates of the

Federal Medicare plan, most state Medicaid agencies in turn

subcontracted their state QIOs to also perform medical decision

making tasks for Medicaid. This is a huge administrative advantage

for the states because it creates yet another barrier between the

state Medicaid agency and the Medicaid beneficiary and further

dilutes Medicaid accountability.

Because these are contractual relationships, the QIOs are under

contract to only allow what is permitted by a state's Medicaid plan.

Of course this is a blatant conflict of interest for the QIO since

EPSDT's Paragraph 5 mandates whatever is " necessary to correct or

ameliorate " , " WHETHER OR NOT SUCH SERVICES ARE COVERED UNDER THE

STATE PLAN. "

In Georgia, the GMCF was the entity that initially denied

reimbursement of HBOT for our son Jimmy’s brain-injury--because HBOT

for cp wasn't covered under the state plan. We had no recourse for

rebuttal because GMCF has no method--or responsibility--for

communicating with recipients. Everything has to be done through

Georgia Medicaid--who in turn declared all decisions are made by

GMCF, and they couldn't/wouldn't interfere--which forced us into

court for resolution.

When Jimmy lost his Medicaid/ Beckett eligibility after the 2006

decision, it was Dr. of the GMCF who made that

determination.

Dr. had testified against Jimmy at the ALJ hearing just two

weeks before.

In that certified letter, the state (by Federal law) was required to

reference the Federal stipulations for determining Medicaid waiver

eligibility. I looked them up, and they're actually very matter-of-

fact, very straight-forward, very easy to understand--as opposed to

the intentionally confusing Beckett qualifications created by

the state of Georgia as found on the Georgia Medicaid web page.

Because 2006 was an election year, we made a few phone calls and

Jimmy’s Medicaid was re-instated. I then asked for a written

explanation as to why he was denied to begin with and why he was then

re-instated--because I knew we had to go through the renewal process

all over again in 2007.

His 2007 renewal application included a " medical history " in which I

detailed all the specifics regarding his case--

beginning with his 2006 removal from Beckett and including his

before/after SPECT scans and still shots taken from Dr. Harch's

remarkable video found at http://www.harchhyperbarics.com/video.htm .

This also included a review of the Federal qualifiers for a Medicaid

waiver. There's a list of I think 10 or 12 qualifiers. #8 on the list

is " initial regimen for the administration of medical gases. " The

medical history is a 3-pdf, 40-page document that's on http://

/group/medicaid/files/ . You're welcome to it.

It's got all the references in it.

I intentionally made it as detailed as possible because--in Georgia--

the rules of evidence for ALJ hearings preclude admitting documents

at the hearing itself unless the person(s) who actually created the

documents are there in person to confirm that they actually created

the documents. This eliminates hearsay evidence from admission. This

means the federal regs I referenced in the medical history could not

be admitted unless the actual bureaucrat who wrote them appeared in

person. The only way around this is if the document in question is

part of the official record prior to the hearing. Any documents

produced prior to the hearing are considered part of the official

record and thus admissible--thus the 40-page medical history.

Well guess what, the " initial regimen for the administration of

medical gases " includes administration of Hyperbaric Oxygen Therapy,

and in fact, on the CMS website HBOT is categorized under #8--which

means a prescription for Hyperbaric Oxygen Therapy (HBOT) from an MD

is an automatic qualifier for a Medicaid waiver--which includes

Beckett.

The beauty of this--for us--as parents: If an Rx for HBOT qualifies a

child for a Medicaid waiver, it would in turn be nonsensical for

Medicaid to then deny the Rx that qualified the child for Medicaid.

Any judge can see that.

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770-491-6776 (phone)

404-725-4520 (cell)

815-366-7962 (fax)

mailto:david@...

fearlessparents/

http://www. .com

http://www.davidfreels.com

[Guest guest]

- where do you take him for treatment? Are you doing it at home?

Freels <dfreels@...> wrote: ,

Beckett is just one of several Medicaid waiver programs.

In 2006, two weeks after a second hearing before the

same Administrative Law Judge (ALJ) who first heard our case in 2000,

we were notified by certified letter that our son Jimmy no longer

qualified for Medicaid under Beckett. The person who made the

decision was Dr. , a pediatric neurologist and medical

director of the Georgia Medical Care Foundation (GMCF). The GMCF is a

quasi-public agency created by CMS (Centers for Medicaid and Medicare

Services--formerly known as the Health Care Financing Administration

[HCFA]).

Medical decision making for Medicare recipients used to all be

performed by HCFA/CMS at the home office in Washington DC. As you can

imagine, this was a cumbersome and nightmarish process that could

take months or even years to make decisions. The solution--20 or 25

years ago a system/network of what HCFA/CMS called " Peer Review

Organizations " (PRO) were created by HCFA/CMS in each state to

perform medical-decision making tasks for Medicare patients in those

states.

A few years ago, HCFA/CMS decided the PROs could also be utilized to

improve the quality of healthcare for Medicare recipients, and now

the PROs are known as QIOs.

Georgia's QIO is the GMCF.

Because the Medicaid plans of most states are exact duplicates of the

Federal Medicare plan, most state Medicaid agencies in turn

subcontracted their state QIOs to also perform medical decision

making tasks for Medicaid. This is a huge administrative advantage

for the states because it creates yet another barrier between the

state Medicaid agency and the Medicaid beneficiary and further

dilutes Medicaid accountability.

Because these are contractual relationships, the QIOs are under

contract to only allow what is permitted by a state's Medicaid plan.

Of course this is a blatant conflict of interest for the QIO since

EPSDT's Paragraph 5 mandates whatever is " necessary to correct or

ameliorate " , " WHETHER OR NOT SUCH SERVICES ARE COVERED UNDER THE

STATE PLAN. "

In Georgia, the GMCF was the entity that initially denied

reimbursement of HBOT for our son Jimmy’s brain-injury--because HBOT

for cp wasn't covered under the state plan. We had no recourse for

rebuttal because GMCF has no method--or responsibility--for

communicating with recipients. Everything has to be done through

Georgia Medicaid--who in turn declared all decisions are made by

GMCF, and they couldn't/wouldn't interfere--which forced us into

court for resolution.

When Jimmy lost his Medicaid/ Beckett eligibility after the 2006

decision, it was Dr. of the GMCF who made that

determination.

Dr. had testified against Jimmy at the ALJ hearing just two

weeks before.

In that certified letter, the state (by Federal law) was required to

reference the Federal stipulations for determining Medicaid waiver

eligibility. I looked them up, and they're actually very matter-of-

fact, very straight-forward, very easy to understand--as opposed to

the intentionally confusing Beckett qualifications created by

the state of Georgia as found on the Georgia Medicaid web page.

Because 2006 was an election year, we made a few phone calls and

Jimmy’s Medicaid was re-instated. I then asked for a written

explanation as to why he was denied to begin with and why he was then

re-instated--because I knew we had to go through the renewal process

all over again in 2007.

His 2007 renewal application included a " medical history " in which I

detailed all the specifics regarding his case--

beginning with his 2006 removal from Beckett and including his

before/after SPECT scans and still shots taken from Dr. Harch's

remarkable video found at http://www.harchhyperbarics.com/video.htm .

This also included a review of the Federal qualifiers for a Medicaid

waiver. There's a list of I think 10 or 12 qualifiers. #8 on the list

is " initial regimen for the administration of medical gases. " The

medical history is a 3-pdf, 40-page document that's on http://

/group/medicaid/files/ . You're welcome to it.

It's got all the references in it.

I intentionally made it as detailed as possible because--in Georgia--

the rules of evidence for ALJ hearings preclude admitting documents

at the hearing itself unless the person(s) who actually created the

documents are there in person to confirm that they actually created

the documents. This eliminates hearsay evidence from admission. This

means the federal regs I referenced in the medical history could not

be admitted unless the actual bureaucrat who wrote them appeared in

person. The only way around this is if the document in question is

part of the official record prior to the hearing. Any documents

produced prior to the hearing are considered part of the official

record and thus admissible--thus the 40-page medical history.

Well guess what, the " initial regimen for the administration of

medical gases " includes administration of Hyperbaric Oxygen Therapy,

and in fact, on the CMS website HBOT is categorized under #8--which

means a prescription for Hyperbaric Oxygen Therapy (HBOT) from an MD

is an automatic qualifier for a Medicaid waiver--which includes

Beckett.

The beauty of this--for us--as parents: If an Rx for HBOT qualifies a

child for a Medicaid waiver, it would in turn be nonsensical for

Medicaid to then deny the Rx that qualified the child for Medicaid.

Any judge can see that.

Freels

2948 Windfield Circle

Tucker, GA 30084-6714

770-491-6776 (phone)

404-725-4520 (cell)

815-366-7962 (fax)

mailto:david@...

fearlessparents/

http://www. .com

http://www.davidfreels.com