Sometimes I Feel Like a Piece of Bologna

Friday, June 29, 2012

Medicare Managed Care Chronicles: After all, she’s 91… … (Part 5)

Mom’s PT documented that she was still progressing, that she was still a fall risk, and that she was benefiting from the exercises and activity. He noted that he had not yet released her to walk independently. He indicated that she is alert and oriented and understands her limitations. He said that statistically, a patient’s diagnostic level drops a level upon discharge to home or assisted living, so discharging prematurely is dangerous. Later in the day he called United Health, and was told that a denial had not been issued, that they were still reviewing the case. That it was still pending. United Health redirected him to the HMO, which confirmed that a denial had been issued. The rep would not budge. She cited Mom’s age, and the fact that they have a fixed amount of money, and Mom had spent that so she had to be denied.

Given the multiplicity of mixed messages, we felt we had no choice but to move Mom to assisted living. She was clearly not ready, but was being forced to a lower level of care that she has to pay for. She was discharged with orders to receive both home PT and OT two to three times per week in assisted living. That didn’t happen. She had a few visits and is now being discharged by home health. No one can tell me why. As a Medicare subscriber, she has the right to receive care to restore her to her prior level of functioning, as long as she is progressing. She was progressing until she was denied that right by United Health and her HMO.

By June 7, I still had not received a decision on the “expedited appeal,” now a week late. I called again and received terrible customer service from United Health who gave me a lot of misinformation. I finally spoke to a helpful supervisor, who offered to receive and forward a summary of my complaint. I wrote up the entire sordid affair and forwarded it to him, but have had not official response. Finally on June 8 I received a written confirmation of the denial--dated May 30!

It’s been a steep learning curve. Indeed, both private insurance and Medicare are already throwing granny under the bus. The elderly are not getting the care they have paid for and deserve. And we aren’t even under Obamacare, which removed $500 billion from Medicare. Folks, we’ll be dealing with this type of ordeal for the rest of our lives, fighting for care for both our parents and for us Boomers who become eligible for Medicare over the next 20 years. If you’re old, don’t expect to have your insurance cover you. Expect age discrimination. Expect to spend many hours fighting coverage battles. And even if you are extremely tenacious, expect to lose.

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Thursday, June 28, 2012

Medicare Managed Care Chronicles: After all, she’s 91… … (Part 4)

When I again spoke to the HMO clerk, she was clear that the decision was hers and she was not willing to reconsider, even though she had considered only the selective portions of the medical record that upheld her opinion. She (who had never seen my mother) declared that Mom had reached her plateau (contrary to the PT notes) and after all, she is 91. The fact that she could transfer from bed and walk with standby was sufficient for to make this decision, contrary to the professionals who know my mother and were working with her! Too bad--there was nothing more she could do.

I was appalled! This is clearly a case of age discrimination and of an insurance clerk overriding the professional opinions of the staff treating the patient – the very thing Americans have feared with national health insurance now happening before my eyes with a private pay patient.

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Wednesday, June 27, 2012

Medicare Managed Care Chronicles: After all, she’s 91… … (Part 3)

The next day (May 31) we learned that the initial denial had been issued by her HMO’s case manager. We had not even known of her existence until this point. This was beginning to feel like a shell game, never knowing who to talk to or who had the authority. I asked her surgeon and PT to help with the appeal. Both agreed and made calls. The PT had run more tests and stated that Mom was still a fall risk. The clerk never returned the physician’s call. Remember, their professional opinions had been overridden by an insurance clerk! And the decision seemed to be age-related. I didn’t think the death panels had been activated yet.

I also called United Health again, trying to figure out who had the authority to reverse this decision. I was told I could file an expedited appeal, meaning they to respond within 72 hours. However, if they upheld the denial we would be responsible for any additional days. The rep said the clinical staff would review all of the information and contact both the PT and the physician for more information. You can imagine the uncertainty this creates for the patient and family, not knowing if the insurance they have paid for and depended on for years will continue to cover needed services. It puts the entire burden of risk on the patient and none on the insurance. Not quite a fair situation! The rep was quite glib in saying that if Mom needed skilled care, of course she should stay in rehab, but of course, he could not assure us that the care could be covered. We decided to keep her at rehab until a family member could move her on Saturday, June 2, not knowing if it would be covered or not. The rep also indicated that if we were denied, there was yet another level of appeal, but it seemed like a moot point since by then she would already have moved.

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Tuesday, June 26, 2012

Medicare Managed Care Chronicles: After all, she’s 91… … (Part 2)

We waited all weekend for a response. Did we need to move her or not? It was a time of uncertainty, which caused her blood pressure to rise and her progress to regress a bit. The rehab facility staff said the delay was unusual. Responses to appeals were usually received quickly, usually within the hour. We were at a loss to know what to do. It was a holiday weekend. No one could answer any questions. Her discharge date was scheduled for Memorial Day. We had made arrangements with Assisted Living, but they could not receive her on the holiday.

We didn’t receive any response until two days after Memorial Day, on May 30 at 4:00 pm when staff informed me that they had received a verbal denial. I called HSAG again. The rep said that the earlier denial would stand. The last covered day would be May 30 (today). I asked her the reason for the denial. She said that the patient was medically stable and ambulating independently for 200 feet. This was not true and not what the record said. The rep said that they had determined that she had hit her plateau. “After all, she is 91.”

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Monday, June 25, 2012

Medicare Managed Care Chronicles: After all, she’s 91… (Part 1)

I confess, I'm still amazed at the craziness of being a GenSandwicher. Especially in dealing with the health care system. And we don’t even have ObamaCare yet! For the next five days, I'm going to share how I've spent the past months of my life. I hope it will alert some of you remain vigilant and determined in seeking coverage for your Medicare- and managed care-covered aging parents. Mom’s insurance is a Medicare Advantage program run by United Health and managed by an HMO. Your experience may differ depending on your specific situation.

Mom fell and broke her hip in mid-April. She was in the hospital for a few days, then moved to rehab for about six weeks. Mom’s last week in rehab was amazingly frustrating. Her physician and physical therapist (PT) agreed that she was making good and steady progress toward reaching her prior level of functioning, which is apparently what the professional standard of care is. Although they recommended she remain in rehab for several more weeks, we had heard rumors that an insurance denial was in the works. It finally came in at 3:00 pm the Friday before Memorial Day. Her last day of covered care was to be on Memorial Day. Really?

All of the rehab facility staff we needed to help with our appeal had already disappeared for the weekend, leaving me with a clerk who had never done a Medicare appeal. In case you also haven’t navigated an appeal, here’s my experience. There is a number you call to a group called HSAG to file a Medicare appeal. After the requisite time on hold, I was asked why I was appealing the decision. I quickly went through all the reasons: she’s still progressing, had not reached her prior level of functioning, was still a fall risk, had not been released to do much without standby assistance, her physician and PT believed she needed more time, etc. I went through it quickly because I assumed I'd be asked clarifying questions. The clerk simply took the information (or so she said) and thanked me. She said that she would forward the appeal to the United Health appeals and grievances department, which could take up to two days to make the decision. When I asked the reason for the denial, she indicated that the patient had reached her “expected level of recovery” since she could get out of bed and to the bathroom. “After all, she is 91 years old.”

Yes, but prior to her fall, she was living independently in her own home, driving the old people around, cleaning, shopping, managing her finances. Living life. To justify the denial they now say, “After all, she is 91 years old.”

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