Recently members of WSHA’s Medicaid Committee met with representatives of the Department of Health Services (DHS). Purpose of the meeting was to follow up on issues presented in February addressing barriers encountered by providers when seeking services for Medicaid members through the prior authorization (PA)/adjudication process. Positive changes obtained from providers were shared:

• number of questions on returned PAs has decreased

• requests for submission of ABA plans of care have decreased

• approvals for members with complex diagnoses over the age of 6 have been noted

Providers have observed a new pattern utilized by reviewers. Approval messages include a list of items to be addressed should a subsequent PA be submitted. Reportedly, this has been helpful and has resulted in approval of subsequent PAs. Providers also reported “cut and paste” questions and requirement to provide language-age equivalents for members with complex habilitation/rehabilitation needs continue to appear on returned PAs.

DHS presented recent data on the adjudication of durable medical equipment, i.e. speech generating devices (SGD). 305 SGDs (98% of submissions) were approved from September 2023 through February 2024. The most common reasons cited for returns on these PAs were:

• missing manufacturer’s suggested retail price (MSRP) for requested accessories

• missing documentation, e.g. PA forms, prescriptions, face-to-face requirements, clerical errors

• request for IEP

• face-to-face and prescription requirements were not met

• functional use of SGD across settings was missing

Members pointed out SLPs provide recommendations for SGDs and accessories, but the vendor frequently fails to provide pricing information. Following collaboration with school-based SLPs it is difficult to obtain IEPs. DHS suggested providers go back to vendors, CESAs, special education directors, Children’s Long-Term Support Council to address these issues.

WSHA’s Medicaid Committee is seeking information from providers on their experience with the PA process. Please submit questions or concerns pertinent to the issues described above and to report other barriers accessing/providing speech/language services for Wisconsin’s Medical Assistance members. WSHA@badgerbay.co (not .com)