I read with concern the Samoa News article, “Governor’s and Medicaid offices team up to support local patient,” 4/10/2025.

On its face, the public might think this was a great thing but in reality, it is one of the worst things that could happen to the Medicaid program. I do not hold it against the patient who had every right to seek help for her situation. Instead, I want to discuss WHY it was bad that Lt. Governor Pulu intervened in this case that may have unduly compromised the policies and procedures of the Medicaid off-island referral program, and putting the program at risk for non-compliance.

No matter how one looks at it, the political intervention by Lt. Governor Pulu was bad because it essentially re-opened the door that politicized the Medicaid referral process. It re-introduced bad practices from the past and set a precedent of improper interference by political leaders that would essentially allow for political abuse, unfairness, and dishonesty to what otherwise was designed to be a fair medical referral process under the Medicaid agency.

If Medicaid is improperly pressured by external political figures, to reverse Medicaid decisions or give exceptions to patients, it puts the program at risk for fraud, waste and abuse. Further, it undermines the integrity of how the Medicaid referral process was designed — to ensure fairness and equal treatment of all patients. 

The first line of the article states, “Lieutenant Governor Pulumataala Ae Ae Jr., took the lead when the Governor’s Office “intervened” recently to provide immediate Medicaid assistance to Mrs. Sherry Ho Chee.” One of the concerns is that this patient case was made known publicly pursuant to a press release, which is clearly a violation of the patient’s HIPAA protected rights — if this disclosure of the patient’s name was not authorized by the patient. The government should not disclose patient names, gender, medical conditions for any reason without the express permission of patients. In any case, to avoid any potential conflict, it should be a standard policy and practice of government not to disclose patient health information.

It is difficult for the Medicaid agency to defend itself from public criticism and how it handles referral cases because Medicaid is prohibited under federal HIPAA law from disclosing personal health information of patients, including the disclosure of their names and medical conditions. No matter the criticism, Medicaid protects and respects the rule of law in protecting patient health information.

There are several checks and controls in this new Medicaid referral program that was approved by the federal government in FY2018. (It took me nearly 4 years to set that up but that is a story for another time.) The referral program that the territory has now, pays 100% medical, 100% travel (air and ground) and100% accommodations. The design of the Medicaid referral program was thoughtfully designed based on past experiences of the past medical referral program. Back then, only LBJ made the decisions on who got referred and who didn’t.

Trust the process. Now, there are three agencies involved and four stages of approval that every patient has to go through, to be referred off-island fairly and properly. No one agency controls approvals or can do approvals alone for referral patients and this was intentionally designed and continually improved, to protect the rights of our people to fairly access the off-island referral program administered by Medicaid.

The only circumstance that I can think of why a patient would seek the Governor or Lt. Governor’s intervention, is because they have been denied for referral for any number of reasons or there is a delay that concerns the patient. Again, Medicaid is challenged and cannot speak to such cases because it is prohibited from doing so under HIPAA.

The referral process has been publicized and even if patients are not familiar with it, the policies and procedures are clear and well-established at LBJ, Medicaid and the providers.

The medical referral program administered under Medicaid has been in operation since 2018 and nearly 3000 patients have been referred. Every patient has a chance for referral so long as they follow the policies and procedures of the Medicaid off-island referral program and are encouraged to follow-up with Medicaid on the status of their referral.

Problems arise when third parties try to intervene in the process. Medicaid cannot speak to 3rd parties about patient cases — they can only speak to the patient and the patient’s legal representatives. It does not matter who the person is, even the Governor and the President of the Senate need to follow the procedures to allow for federal reimbursement.

Again, following is an abbreviated explanation of the 4-Step approval process for the Medicaid referral program. These steps are in fact audited by CMS, to ensure proper federal funds reimbursement.

Step 1. LBJ approves. The patient’s doctor must submit a request for the patient’s off-island referral to the LBJ Off-Island Medical Referral Committee. Once LBJ approves a patient (whose medical condition CANNOT be treated at LBJ), the case is uploaded into the Medicaid system that documents submission date and time. Medicaid cannot act on any referral, unless it has been submitted officially through Medicaid’s online system that is accessed only by LBJ and off-island providers.

Step 2. Medicaid approves. Once received through the Medicaid patient portal, the system immediately sends out an alert to the Medicaid staff that a new referral has been received into the system. Depending on the urgency level of the patient case, the Medicaid must process it within 24/72 hours (workdays) to review and approve patient eligibility and “medical” eligibility (not all medical conditions are covered under the Medicaid State Plan.)

For MedEvacs, the system alerts the appropriate designated staff 24/7. All referral tasks and communications are done on the system and therefore well-documented and transparent. Once approved the system alerts the off-island providers that a patient has been approved by Medicaid and ready to be reviewed and accepted by the receiving facility off-island.

This Step 2. eligibility review and approval stage is required under federal law and cannot be bypassed.

Step 3. Off-island provider approves. The off-island providers review the patient cases and determine the urgency and need for acceptance. Sometimes a provider will respond and say there is no need for referral, LBJ is doing appropriate care that they would also do; or they may request additional medical information from LBJ to make a decision; or they may respond that the patient needs to be sent immediately; or they may respond and say it is not urgent according to their read of the medical notes and they will schedule the patient based on their availability; or they may say that they will teleconference consultation to treat the patient at LBJ. Any number of reasons can delay acceptance.

If being referred to NZ, delays can also happen for immigration reasons because all patients and escorts need “medical” visas. Once the provider ACCEPTS the patient and informs Medicaid of the acceptance, Medicaid works with LBJ and the off-island providers to coordinate the logistics for referral.

Step 4. Medicaid approves funding. Once the off-island provider accepts the patient and provides an estimate of the costs and duration, the final stage of approval is done by Medicaid to authorize the use of federal Medicaid matching funds for the patient.

There must be medical treatment covered by Medicaid to trigger the ancillary Medicaid benefits of transportation and accommodations coverage. Medicaid cannot cover for travel and hotels, unless it first covers the medical treatment costs which is the primary reason for referral.

Exceptions are made for Medicare patients so long as they are treated by authorized Medicaid providers. So long as there is sufficient local match, Medicaid issues what is called the Guarantee of Payment (GOP) to allow for reimbursement to the provider. This is the final approval and straightforward.

During my tenure, I suspended the referral program because the demand on referrals was higher than could be supported by the local match funding. This was to take preemptive protective action to protect the program from being terminated by our off-island providers, and to protect the credit and business relationships of the Medicaid agency.

Political intervention into Medicaid patient referral decisions was a risk that I adamantly advised against when I worked for former Governor Lolo and Lt. Governor Lemanu.

As an experienced policy maker and a thoughtful leader, Governor Lolo recognized the value of protecting the Medicaid program from undue influence and of not undermining the authority of the Medicaid agency that is tasked to administer the program in compliance with federal law. The checks and controls in the program work and referrals are managed fairly and equitably regardless of the noise that is sometimes made because of ignorance or misinformation.

Medicaid has designed a good referral process never before done in the territory, and the territory now has a fair and equitable referral model to follow — so long as politicians don’t get involved in the process.

There is no favoritism in the Medicaid procedures. Everyone has to follow the same rules because if an approval step in the 4-step referral process is missing, the internal checks and control system within the Medicaid program will catch it and the Medicaid office will have to explain why CMS is denying reimbursements and requiring ASG to refund Medicaid dollars back to the federal government.

I pray that the Pula and Pulu administration and all elected leaders understand that they must refrain from interfering in Medicaid referral decisions.

Federal law already exists that places strict regulatory requirements on the administration of the Medicaid program. Undue influence from political or business leaders politicizes the medical referral process. Interference emboldens people to bypass Medicaid procedures by pressuring political leaders to intervene for any personal or political reason — whether the patient is eligible or not or they followed procedures or not. That is abuse, fraud and unfair. We then fail to learn from history — when prior administrations were forced to make decisions based on political pressure by “who you know” — to decide who gets to go off-island. The very people who cry for honesty in government are often the very same people who when they find themselves in an unfavorable situation, now seek political intervention or favors to get what they want — regardless of the negative impact on the collective wellbeing of our community. This disservice undermines public confidence in a life-saving program that our people need. Our territory cannot repeat the mistakes of the past, that terminated the previous medical referral program for nearly 10 years before it was re-established under Medicaid in FY2018.

It is destructive and damaging to the Medicaid program and to the territory, when people on social media criticize from a place of ignorance, misinformation and worse DIS-information.

People should know that such unfounded criticism without knowing the facts, damages our government’s business relations with medical providers and the federal government and as a result, puts our access to the Medicaid program at risk. We end up hurting ourselves, our families and the very people we are trying to serve.