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Dr. Rossi
Dr. Rossi, Psychotherapist
Category: Mental Health
Satisfied Customers: 4627
Experience:  PsyD, LPC, CHt
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I am having a problem with insurance. Medicaid has denied me

Resolved Question:

I am having a problem with insurance. Medicaid has denied me coverage and because the MICA clinic i have been going to daily is now not going to be paid in full right away, they are barring me from all appointments. I am on Suboxone, Vistril, and 150mg Suboxone. If I don't secure my scripts tomorrow, I will go into withdrawel on Saturday. Is this lawful? Can they do this to me when they know I am opioid dependent, have panic and anxiety tremor, and have been hospitalized for a suicide attempt? What can I do to advocate for myself and prevent withdrawel and severe depression?
Submitted: 4 years ago.
Category: Mental Health
Expert:  Dr. Rossi replied 4 years ago.



You would want to contact your insurance (Medicaid) and ask to speak to a care manager. They may not pay the fee if the service is an excluded benefit. There is no way around that.


On the other hand, if this is a covered benefit (some insurance generally pays for medication but not the doctor's visit) and if that is the case, you will be responsible for that payment. The clinic also must be on the Medicaid panel for payment if you have coverage for suboxone (it may be out of network )


The only one that can assist you with this is Medicaid (your insurance carrier since they are the payour) You want to find out if the benefits are covered and if they come out of your medical or mental/substance abuse portion of the coverage. If the benefits are not covered, they won't pay no matter what. You can ask them in that case, should you go into withdrawal, what would be the next level of care you're going to be able to access that they cover (rehab/in house detox, methadone, etc)

Customer: replied 4 years ago.
You answered what I asked but I worded it in a way that made you believe that my claim was denied. My APPLICATION was denied. The clinic was allowing me to attend because I am in crisis and was referred to them by the hospital I was in after the suicide attempt. Because I had a pending letter they prescribed meds, gave me therapy, etc. Now that they know that I am appealing the medicaid denial, which they only know because I told them, they have sprung into action to deny me treatment. What I was trying to find out is if it is not only unethical, but also illegal for them to deny me medication that If I don't have will arguably put me and other people in danger. Can I say with confidence that they are breaking the hippocratic oath? Can I threaten to level charges, other than a cilvil suit?
Expert:  Dr. Rossi replied 4 years ago.

You may interpret it as you wish. They should not stop your medication cold turkey or should make provisions for you to obtain treatment elsewhere before they discountinue seeing you. But, the fact remains- they did it to you. A claim is usually denieid for these main reasons 1/ the service is not a covered benefit, 2/ a person had maxed their benefit for the year, 3/ the service for which they are billing does not meet medical necessity criteria 4/ services were obtained by an out of network provider

Whoever is in charge of approving your appliation would be the main entity to deal with. If your medicaid covers this benefit (and you have to make sure that they absolutely do both medicaiton and doc's visits) then you can always appeal it. Usually you have 3 times to appeal the insurance's decision.


Customer: replied 4 years ago.
I don't have medicaid. I am uninsured. I was told at the hospital that I would be approved for emergency medicaid if I complied with thier medicaid office and turned in my birth certificate, rent information, etc. I would not have made the decision that led me to the MICA clinic and incurred these charges if I had not been led to believe that I was eligible for Medicaid insurance and that the coverage would be retroactive to the date that the HOSPITAL put in my application. It wasn't until a month later when I was discharged from a mandatory psych hold that I learned from the local Medicaid office that they had no application of file, and that medicaid would only be retroactive to the day I applied personally at their office. So the application that I believed would be approved based on the hospital medicaid rep telling me so, was not put in and was not honored by medicaid proper. Through the hospital, with the understanding that straight Medicaid would cover the charges, I wound up at Bridge Back to Life, a for profit organization. I have been going there faithfully, following the program without relapse, taking meds as prescribed. I was dumbfounded when the medicaid application was denied because I was forthright about my income (Unemployment) from the first step. The federal Dr. told me I was temporarily disabled and to continue going to treatment. Then the application was denied and the MICA program won't even let me see the doctor to renew my scripts, so that I will be physically able to make preparations to begin to pay the balance. Because I can not pay in full tomorrow, I will not have m scripts renewed and will begin to get sick on Friday morning. I am desperate. What can I do?
Expert:  Dr. Rossi replied 4 years ago.
In some cases you can ask the doc to give you a bridge prescription with enough meds to hold you over until you have the insurance activated or come up with the fee they are trying to get (if there is a possibility that would happen=getting Medicaid) If the doc at this specific clinic refuses, you may try getting a bridge prescription from the ER or a different doc if they deal with the suboxone (not all physicians handle that and have to be credentialed specifically for it) If you have not spoken to the hospital rep but only the billing office, make sure that you do so. They are supposed to advocate for you especially when you were told they are handling your case from the start. Find out should you go into withdrawal, where you can go for treatment. Even those who are uninsured or don't have Medicaid, have to have access to treatment usually at the state hospital. The issue is to see if they provide suboxone there. The hospital may have other funding options available and you'd have to explore if they use care credit (you can apply for this from your home online)
Dr. Rossi, Psychotherapist
Category: Mental Health
Satisfied Customers: 4627
Experience: PsyD, LPC, CHt
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