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Lincoln judge affirms denial of Medicaid coverage for skilled nursing facility care for guard shot 6 times

Lincoln judge affirms denial of Medicaid coverage for skilled nursing facility care for guard shot 6 times

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A Lincoln judge has affirmed the denial of coverage for skilled nursing facility care for an Omaha security guard shot six times who now is a paraplegic.

In a 14-page decision, Lancaster County District Judge Susan Strong said Quality Living Inc., which had sought the authorization retroactively, failed to meet its burden to establish that skilled nursing care was a medical necessity.

On July 28, 2018, a 63-year-old man was paralyzed after he was shot six times while working as a security guard at an Omaha gas station. He underwent multiple surgeries at the University of Nebraska Medical Center during a two-month stay, then was transferred to Madonna Rehabilitation Hospital for two months, according to court records.

When he was discharged, he went to QLI, a licensed, special-needs nursing facility in Omaha with a contract with the state of Nebraska to provide care for Medicaid, long-term care clients.

On Dec. 13, 2018, QLI sought retroactive authorization from Nebraska Total Care for the man's care from Nov. 19 to Dec. 12.

Nebraska Total Care, which provides services to Medicaid-managed care enrollees under the state's Medicaid Assistance Program and has a provider agreement with QLI, reviewed the request and denied it for lack of medical necessity.

Two doctors reviewed the records and concluded that, when the man left Madonna, his care needs could have been met with the help of one person and could occur at a lower level.

They said his medical condition was "not so complex or complicated that he needed skilled services during that time frame," according to the order.

Last June, QLI appealed the denial to the Nebraska Department of Health and Human Services' Division of Medicaid and Long-Term Care, which held an administrative hearing in September, where QLI offered the testimony of a doctor who said he would have approved the request to counter Nebraska Total Care's doctors.

The following month, Matthew Van Patton, then director of the division, affirmed the decision to deny reimbursement, saying the records that QLI submitted to Nebraska Total Care did not demonstrate that skilled nursing facility care was medically necessary.

The patient didn't qualify for skilled nursing facility care because he "did not have any identified goals, had met nearly all of his goals at the acute rehabilitation facility, and could receive a less restrictive level of care," according to the decision.

In November, QLI petitioned the Lancaster County District Court to review the decision.

In an order last week, Strong said Nebraska Total Care and the department had properly relied on the opinions of physicians "who employed standardized criteria for admission discernment in addition to their clinical judgment when reviewing the medical records submitted by QLI."

She said the doctor, nurses and therapists at Madonna who authorized skilled nursing services hadn't been focused on medical necessity.

Reach the writer at 402-473-7237 or lpilger@journalstar.com.

On Twitter @LJSpilger

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