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New method of doing evaluations for PCA hours and "restrictions"

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    New method of doing evaluations for PCA hours and "restrictions"

    I recently had the most dehumanizing experience and 8 hours cut from my PCA hours because a robot (an algorithm) now decides your care plan. The nurse came in with a computer that was attached "live" to Medicaid. She totally disregarded all my previous evaluations, docked me by 8 hours, then proceeded to say I was not allowed to have any of my care outside my home. Here in Massachusetts they encourage people with disabilities to go out in the community to work, volunteer, go to school and partake in hobbies and social events. I have NEVER been told that before. Also the nurse made vailed threats about nursing homes and as the evaluation progressed things that were important like pericare, setting up and cleaning my nebulizer, upper body PT, some aspects of bowel care, were eliminated. She then proceeded to say I was not allowed to appeal the decision.

    I was humiliated,irate and felt it was a dehumanizing experience by the time she left, but said nothing. I did not want to endanger my services for independent living, or appear out of control. After making a number of phone calls, I found this nurse way overstepped her boundaries. In fact my doctor's nurse Practioner felt she was WAY out of line. I received a call from the Director of Community Services and the PCA Program at Medicaid. She was very angry, and felt this nurse had said some very untrue things. She told me I was definitely allowed in the community and that is why the program is set up the way it is, and that yes, I am allowed to appeal.

    Today I received my notification from the Medicaid stating that I was "approved", but not for my original hours. I had spoken to my doctor and they said they had not signed the paperwork and we're putting together a letter demanding a new eval and a return to my original hours including the services I need. Apparently, it appears the nurse may have forged my doctor's name, or it was signed in a hurry when the paperwork came across his desk.

    Medicaid or the agency have set up a contract with a company based in Minisota named Optum, and they use an algorithm to decide your care, NOT a human being. As far as I am concerned I refuse to accept a decision made by a machine or robot for my care or things that personally affect me, which is what an algorithm is. I was ready to leave the PCA program, but know it would be "slitting my own throught" without this care, so I have stayed.

    Also, the skills trainer today kept agreeing with the nurses, at which point I blew up and told her in uncertain terms that my information came from the person who is the Director of Community Services and the PCA program AT MEDICAID, and I go by what she says, not some nurse from an agency.

    The skills trainer also said that many other consumers are angry and have complained about how they were treated also. Don't get me wrong, the skills trainer is a great person and I like her a lot, but I think as a worker for the agency, he had to stand behind what they said.

    I, at this point have seeked legal assistance through the Health Law Advocates, and they are also looking at some other unpaid medical bills I was stuck with to see if I can get those covered also.

    Has anyone else had this experience with Massachusetts Medicaid? If so, what steps did you take to resolve it? Does anyone know anything about this company Optum? Who are they? Do I have any rights against them and the decisions?

    Thank you in advance for any help you can give me.
    Disability is not a medical problem with social issues, but rather a social problem with medical issues.
    Franklin D. Rosevelt

    #2
    Just wondering if you have contacted a center for independent living in your state. They are run mainly by disabled individuals and provide information and resources. It might be worthwhile to give them a call to see if they have any suggestions. It would help them too, to learn how you are being treated - there are probably others in your situation that would support legal remedies.

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      #3
      United Healthcare owns Optum. Optum is *fantastic* at cost control and a huge revenue stream for UHC. A lot of what you can do depends on your states contract with them. Optum is often contracted to manage services for “dual enrolled” folks - people using both Medicaid and Medicare - because it’s a very expensive population and an easy target for cost cutting. I wish you luck. UHC is a behemoth and patients are not at all their priority. I did some contract work for them before I was injured and the stuff they are willing to do to cut costs is obscene.

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        #4
        Originally posted by annev308 View Post
        United Healthcare owns Optum. Optum is *fantastic* at cost control and a huge revenue stream for UHC. A lot of what you can do depends on your states contract with them. Optum is often contracted to manage services for ?dual enrolled? folks - people using both Medicaid and Medicare - because it?s a very expensive population and an easy target for cost cutting. I wish you luck. UHC is a behemoth and patients are not at all their priority. I did some contract work for them before I was injured and the stuff they are willing to do to cut costs is obscene.
        I just got off the phone with my doctor's office and they are NOT pleased. My initial injury was caused by medical error in a FEDERALLY funded clinical trial. They administered the wrong blood type when I was an infant. Then my parents were lied to as the cause. It wasn't until I was in my 30's that I found the truth about it by my neurologist at that time telling me. As a result I have developed other problems as well. I am not a pithed frog that someone can experiment on and then lie to and thrown away. I made every effort to get an education and tried to work. Every time I would start working in any job, and I took many low paying entry level jobs to prove I was willing to work my way up. It never went anywhere. I would always end up in the hospital with pnumonia and have to quit. I tried at least 6 times. After that I worked part time or volunteered as I felt I should be a contributing member of society. I do not think I should be punished because I am "expensive". I did not cause it. I am not going to be thrown away!

        I am thankful that there are people willing to listen to my case, and I have The senator, director of community services, and health law advocates involved.

        Thank you for giving me this information, as it will be most helpful in my case. Thank you!
        Disability is not a medical problem with social issues, but rather a social problem with medical issues.
        Franklin D. Rosevelt

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          #5
          I hope this all gets resolved quickly for you. I encourage you to use your advocates and any community resources.

          Also, be aware that they often talk about time in units, and a few years ago, they were cutting their time unit measure from 10 minutes to 6 minutes, on the grounds that few consumers would look at the time allotted and would instead just accept the unit measure and not realize what was going on until it was too late to appeal. it’s something worth keeping an eye on.

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