Sometimes I Feel Like a Piece of Bologna

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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