Treadmill trouble: A mother’s battle for special needs coverage in North Carolina
A mother had to apply again and again through Mecklenburg County’s LME/MCO to get the approval for her daughter’s treadmill.
CHARLOTTE, N.C. (WBTV) - A mother calling for change after an exhausting battle to get her special needs daughter a treadmill. Our WBTV Investigates Team is digging for answers about what went wrong with the approval process for her insurance, the new managed care organization in Mecklenburg County.
The pandemic wasn’t kind to Rachelle Phillipe, who goes by Chelley, according to her mother Marie Phillipe.
“She was unable to go out in the community because she was not as active as she used to be prior to COVID she gained weight,” Marie Phillipe said
Chelley is special needs and is on the NC Innovations Waiver. It’s serviced by Mecklenburg County’s new managed care organization Alliance Health, which took over for Cardinal Innovations.
“She gets caretakers that basically help me care for her during the day,” Phillipe said.
“She’s got people who actually advocate for her.”
But the weight was a bit of a problem. With some help, Phillipe found a part of the policy that would give Rachelle $2,000 to buy a treadmill.
“It shouldn’t have been a problem,” Phillipe said.
Phillipe was denied twice, even though she says her claims satisfied all of the requirements in the policy, including a doctor’s note prescribing the treadmill.
“They kept giving me other policies which I knew didn’t apply and I said if you guys just give me a call, we can discuss this. I pleaded for people to call me, and they refused,” Phillipe said.
But Phillipe made calls and emails, including to Mecklenburg’s Assistant County Manager, Anthony Trotman. She never heard back but the ball got rolling and Rachelle got the approval to buy the treadmill.
But curiously, they asked her to find a cheaper option, even though that’s not mentioned in the policy.
“They told me to find something that was $1,000, which I don’t know why would that be even necessary. I mean, it didn’t make any sense to me,” Phillipe said.
Phillipe must go through Alliance’s “Utilization Management” to get approval. And according to external quality reviews done by the Carolinas Center for Medical Excellence, Alliance has “weaknesses” year after year in that category. That includes deficiencies in monitoring and evaluating certain clients and inconsistencies in procedures and handbooks.
Because Phillipe kept making calls and sending emails, NC Medicaid required new training for Alliance and every LME/MCO to familiarize with the Innovations Waiver policies.
But Phillipe said she’s sharing her story so other families know to keep fighting and to reach out for help.
“I fear for people who really don’t have a voice in this or don’t know exactly what to do to advocate for their for their children,” Phillipe said.
“I do want to make noise so that other families can hear these stories and that they know do not give up just because they say no, there are options out there.”
WBTV reached out to Alliance. In an email, they refused to answer most of our questions citing HIPAA but did answer our questions about what they’re doing to prevent this again writing – “All Utilization Management staff members are responsible for participating in Inter-Rater Reliability activities and practices. The State provides technical support and assistance regarding clinical coverage policies when needed or requested.”
If you’re struggling with finding special needs assistance in North Carolina reach out to the WBTV Investigates Team and share your story. You can email us at firstname.lastname@example.org.
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