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Lawmakers concerned about “red tape” for Medicaid off island referrals

Sandra King-Young and Epifania Solofa Iosefo

Pago Pago, AMERICAN SAMOA — The Off-Island Medicaid Referral Program (OMRP) is running smoothly according to Medicaid Office Director Tofoitaufa Sandra King-Young during the joint hearing of the Senate and House Budget and Appropriations Committee last week.

However, some lawmakers stated that everything has become so complicated since the Medicaid Office was put in charge of the OMRP.

Senator Malaepule Saite Moliga pointed out that getting patients off-island to get treated is so difficult nowadays compared to when the program was run by LBJ.

“The only thing I’m not happy with is the director’s comments concerning some of the patients referred by LBJ doctors for off-island treatment, where she says that they, for some reason or other, are not eligible for off-island treatment,” Sen. Malaepule said. “Yet she admits that they are not doctors, which leaves me wondering who is not doing the right thing.”

House Speaker Savali Talavou Ale wanted to know why there was so much red tape when LBJ doctors refer a patient to the Medicaid Office for the off-island referral program.

“Who exactly determines which patient should be referred off-island for treatment?” House Speaker Savali asked. “There are LBJ doctors and a Board of Directors. They are the ones who determine which patient should be referred off-island. And now, your office has hired your own medical doctor to do the same job.”

Director King-Young clarified that their office does not initiate the referral.

“It is the LBJ doctors who determine which patient should be referred off-island for treatment,” she explained. “After that determination, there are steps taken by my office to protect the program from fraud, waste and abuse, because that is my legal obligation as Medicaid director.

“Before, all that was done by the hospital, so of course we often heard allegations of abuse. That’s not the case anymore. Now there’s a process, and our office screens the patients if they are eligible and if the service they need is a covered service under the Medicaid State Plan.

“Then the hospital in Hawaii or New Zealand has to accept the patient and then the final approval from our office if there are sufficient funds for a local match to draw down the federal funds to fund the patient’s treatment.”

The Medicaid director reiterated that the role of the LBJ doctors still remains, which is to determine which patient should receive off-island medical treatment.

“The OMRP must be initiated by LBJ doctors,” she emphasized. “But we must also remember the financial problems we encountered in the past concerning unpaid bills which led to the suspension of the off-island referral program.

“The only reason the off-island referral program is still ongoing was because her office had to take charge so as to stay in compliance with the Medicaid State Plan.

“That is the only reason why the federal government has allowed us to do the program because there is no trust and no credit with the LBJ Hospital.”

Director King-Young stated that her office has done everything in their power to protect the program from fraud, waste and abuse.

She revealed that there have been attempts by some residents who go overseas to circumvent the rules by applying for the OMRP, but she has been able to prevent this from happening because of the checks and control they have put in place. That is, every off-island referral application must be initiated by LBJ.

Senate President Tuaolo Manaia Fruean raised the recent appointment of Dr. Annie Fuavai as Medicaid Medical Director and asked if the position requires an MD.

“The requirement under the Medicaid, is someone who is licensed by our Health Services Regulatory Board,” the Medicaid director responded. “However, our office requires a qualified doctor who is familiar with the different services offered by LBJ to help us screen referral cases to make sure that the referral cases are legitimate and the services that are being referred off-island are truly services that cannot be treated at LBJ. That is why I have appointed Dr. Annie Fuavai because she has worked for more than 30 years at LBJ.”

The Medicaid Office budget for FY 2024 totals $85.7 million with the number of employees at 21.

This is compared to the current fiscal year which has a budget of $89.2 million and a total of 18 employees.