Sometimes I Feel Like a Piece of Bologna

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.”

Photo Credit iStockPhoto

Labels: elderly parents, HMO, Medicare, rehab, United Health