Cheryl – Indiana

Cheryl’s Story

My elderly father, now deceased, had a series of strokes. Then, he had a worse stroke. It was determined that chips of plaque were coming loose in his carotid and moving up to the brain, and a procedure was done to clean the carotid. His Medicare Advantage Plan had a $5,600 out of pocket maximum, and by the time the procedure was done, he owed that much. This, we understood, as that was the terms of the plan. However, I was very distressed about what came after. The hospital said that he needed a period in skilled nursing during recovery from the stroke and the surgery, which we could clearly see. He could not even drink without choking, unless someone was pinching the straw. He could not walk at all without 2 assistants, and he could hardly sit up in a chair. His speech was very affected (before the procedure), and he was still struggling to speak. The hospital said that the Medicare Advantage Plan had denied the stroke rehabilitation facility they suggested, but they gave us some other options. We chose the one that was closest to our home, so that we could at least visit often. Within days, we got a letter that the insurance would not pay for his rehabilitation. My elderly mother was very upset, and it almost made her sick. They said he did not even need physical or occupational therapy. We were shocked. He could not even scoot up to a comfortable position in his bed at the facility when we were ready to leave for the night without my husband and I pulling him up. I could clearly see, by the wording of their denial, that this was a robo-denial, and that they had not even looked at his recent medical records. I had to file an appeal, but the deadlines were very tight, and they were slow in mailing us the paperwork. This was a complicated process, and my Dad could not sign his name in a way that looked like his normal signature. We had to take a notary with us to witness his signature. (I was not yet a POA, so I couldn’t sign for him.) After we mailed in the appeal, they requested that even more paperwork be sent in, again, needing a signature, and again, with a tight deadline. We had to get a notary again to go with us to witness his signature, and he was still barely able to do more than scribble. A short time after the appeal process was completed, I received a phone call at work. I don’t even know how they got my number. The Medicare Advantage Plan representative was asking me to send an email to withdraw the appeal, because he said the denial did not refer to the facility where he was taken, but only referred to the hospital recommended facility that they had already said they were not agreeing to. I was having a busy day at work, and was uncomfortable receiving that type of calls at my workplace. I told him I would have to go back and look at the original denial. When I looked at it again, it was as I remembered; it mentioned nothing about any particular facility. It simply gave all kinds of inaccurate information about why rehabilitative services were not needed. I called the insurance back and told the person that had called that I could not withdraw the appeal because no particular facility was mentioned and because the denial made all types of statements about his medical condition that were not true. He then told me that the insurance was not going to cover this, anyway, because it did not get pre-certified. The hospital had told us that this facility would be okay, so we thought that had already been taken care of. I was so upset, I thought I was going to have a stroke of my own. My Dad was going to need at least 2 months of in-facility rehabilitation, so I knew that the bill would likely be about $20,000.00. I had to go to the clinic where I worked to have my blood pressure checked, as I felt like I was about to pass out. I struggled with this Medicare Advantage plan for months. Every vacation day that year was for the purpose of calling the insurance. Finally, after constant effort, I got the rehabilitation facility bill paid. After he was released, he needed some outpatient therapy. I never got a letter of denial for that, so I thought it was all okay. After almost a year, I got an email at work from the rehabilitation facility. Again, I was caught off guard, and I felt like I was going to be sick. It was actually around $3,000.00 that they were saying he owed (posted in two increments) that had not been paid, but the way the $700.00 component looked on the initial spreadsheet I viewed, I thought it was saying $70,000.00. We never did get the insurance to pay that bill, but because my husband ardently complained that they had not filed proof that it had been pre-certified, the facility finally agreed to write off the $3,000.00. A short time after that, we got notice that this Medicare Advantage Plan was being pulled from the market. We took that letter to a local insurance broker to try to figure out what to do, as both of my parents had pre-existing conditions. We were told that the notice was their “get out of jail free card”. It enabled us to put them in a Plan F Medicare supplement without a pre-existing condition review, which we would not have been able to do otherwise. After that, we never had trouble with the Plan F, because the law requires that they pay their 20% of whatever Medicare designates as the total cost. At their age, Plan F was expensive, but it was worth it. We did have some trouble after that with billing errors (the provider’s issue), but those issues were much easier to resolve. My husband and I decided we never wanted Medicare Advantage. We also planned to choose Plan F, when became eligible. We knew that old people often get too confused to deal with deductibles, etc., and end up paying things they don’t owe because of billing errors they don’t catch. My husband became disabled and had to go on Medicare early, but in Indiana, Medicare Advantage was his only option before the age of 65. I was so afraid of Medicare Advantage, I kept him on my workplace insurance, which was chopping the heck out of my paycheck, but which still had a high deductible and a high maximum out of pocket. After the experience with my father, I was afraid to deal with a Medicare Advantage plan again. By the time he was 65, Plan F was no longer an option. He took Plan G. At least it had a small deductible, but it is still likely to cause confusion when we get very elderly. I still very much prefer it to Medicare Advantage. My husband has had a lot of health problems, so I have struggled with private, for-profit insurance my whole life. I feel like half of my life has been spent on the phone with insurance companies. Worse, my husband almost died once, and was left with a lot of long-term damage, because of the actions of utilization review when he was in the hospital with a massive DVT and PE. I was so looking forward to having Medicare with a Plan F supplement, for both of us, and now I find out they are doing this direct contracting (conveniently renamed ACO reach). This will undermine original Medicare and may eventually kill it. If we get stuck on Medicare Advantage or some other type of private insurance for the rest of our lives, I hope that God will take us home soon, rather than leaving us here to spend the whole remainder of our lives fighting with insurance. I don’t know that I can do this, when I get really old, and my husband is already incapable of dealing with these types of phone calls, computer navigation, and paperwork.

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