22 Oct
2013

Being a Medicare Advocate

by manoftaste.de flickr.com

by manoftaste.de flickr.com

I’m back to the advocacy topic that I talked about before. Some of you in the Sandwich Generation or with aging parents will face the Medicare system when you are dealing with someone in the hospital. In my case, that someone was my mom during her knee surgery. I won’t go into all the details about her condition, but basically, she had the surgery on a Monday, was supposed to be at therapy that afternoon, and go home on Thursday with home health care. Because of a lack of sufficient pain management by the hospital staff, she was not ready to go home on Thursday. She could barely feed herself.

So, when the nurse practitioner (because we never saw the doctor until FRIDAY) from the doctor’s office came in on Thursday morning and said something like: “Your mom is not participating in therapy. If she refuses to participate in PT, then she’ll be released from the hospital. Medicare is not going to pay for your mom to lay in a hospital bed and do nothing.”

My mom WANTED to participate in PT. She went down there even though it sometimes made her close to vomiting. She tried to listen to what the PTs wanted. She couldn’t. She couldn’t do it. I was there, and I know.  So, I said to the NP: “She’s not refusing to participate in physical therapy. She can’t.”

She shrugged her shoulders and said, “Well, you need to encourage her to try.”

So imagine my surprise when right after lunch the VERY YOUNG social worker came down and said, “So, your mom is being released.”

If someone could have taken a photo, I’m sure my mouth would have been wide open in shock and disbelief. I was livid. I said, “According to who?”

The social worker said that the nurse practitioner had written the release papers for that afternoon.

OH. MY. GOD.

So, I said, “Well, look at my mom. Look at her. She can’t go anywhere today. She can’t go home. We can’t take care of her. You don’t know if there’s a bed for her at the rehab center. SO, what are we supposed to do? This woman is sick.” (They acted like since she couldn’t do her PT, she was refusing to participate and it had nothing to do with a medical condition or the fact that the pain medicine wasn’t right.)

That’s when young social worker said, “You can appeal the decision with Medicare. Once you do that, your mom will have about 36 hours (until Saturday afternoon) to stay here, even if the appeal is denied.”

Dealing with insurance companies is worse than 1. buying a new car  2. going to the DMV and getting your driver’s license  3. getting dentistry work done. REALLY–it’s awful, but I had to do it. If I didn’t appeal my mom’s release with Medicare, then they wouldn’t pay for any more time she laid in that bed while the doctors and nurses tried to figure out the pain medicine and get her to take therapy. My parents would start footing the bill.

Before young social worker left, and I had decided to appeal with Medicare, she turned to me and said, “You know, your mom is really lucky to have Medicare. You should see what it’s like with people who have private insurance.”

I called Medicare, and really the process was pretty painless. A nice woman took the information and listened to me go on and on about why my mom could not be released. She said someone would call me in 24 hours to tell me if the appeal was denied or not.

During that time, the pain medicine was adjusted; my mom could eat more, do some therapy, and actually got a bit better. SO when Medicare did deny the appeal, it was no big deal because then the rehab center had a bed for her and she could travel there.

SO, what did I learn?

1. Listen to the social workers–even the  young ones. They know the ins and outs of the system. You have to play the insurance game.

2. You know your loved one better than the medical professionals. My mom is not defiant. She wouldn’t just NOT do therapy like they were saying. I knew there was something wrong with her.

3. Ask for help. My husband stayed home from work that day with our kids, so I could help my dad deal with this Medicare stuff for my mom.

The thing about being lucky–I realize now that she was lucky to have good insurance. But that’s the last thing that a loved one wants to hear when getting on the phone to appeal a decision with that same insurance company. It doesn’t feel so lucky.

 

9 Comments

  • Luckily when my husband and I took our “in sickness and in health” vows I’ve remained healthy through our years of marriage when he’s been in and out of hospital procedures a handful of times. I learned early on that you look everyone in the eye, speak firmly, and don’t back down because you’re the only one between your loved one’s health and bad care. Here’s the classic case in our family saga…

    One day I came home from work before noon because my kid’s school called and she had an ear ache. I called the pediatrician and we had a 3:00 app’t. By 1:00, my husband was crawling through the front door with a severe stomach ache, and headed for bed. When I check on him right before we were leaving for the pediatrician, he seemed worse, so I called and cancelled that app’t and called his doctor, who said bring him in. My husband argued, but we were at his MD’s office just after three, and by 4 p.m. he lay on a gurney in the hospital waiting for an “emergency” appendectomy. Just after 7 p.m. they finally wheeled him into surgery (yes, that’s right–he waited three hours in a flimsy gown on a gurney in an empty ER room so he could have ’emergency’ surgery). But that’s not the best part.

    They told me the surgery would be brief, and the doctor would come talk to me afterward. Another FIVE hours later the doctor finally came to tell me it wasn’t his appendix, but that his belly button hadn’t sealed properly when he was a baby, and bacteria entered his system that way and turned part of his intestines gangrenous! They had needed to cut him stem to stern to find out what the problem was, and took out several inches of small intestines, But that’s still not the best part.

    This was Monday. By Wednesday–when he was still on a morphine drip, and the hospital had still not been able to stabilize his blood pressure–a discharge administrator met me in the hall as I was leaving my husband’s room that evening, and said, “We’ll be discharging your husband in the morning. If you’ll be here by 11:00 we’ll have all of his things packed to make it easier for you to load everything.”

    I was in shock! I had to ask her to repeat what she said, as I was sure I’d somehow misunderstood. Nope, she said almost everything word-for-word as before. I said, “But he’s still on intravenous morphine, and the doctor said his BP is more than 50 points too high.”

    To which she replied, “Regardless, we have to release him. The insurance said this procedure only requires three nights stay, and tonight is the third night.”

    So, I calmly pulled a notepad and pen from my purse and asked, “Fine. I need to know the name of the hospital’s attorney, and any attorneys who represent the board of directors. And while I’m at it, I’d like your name and your attorney’s name as well.”

    Her eyebrows shot up to her hairline. “Why do you want to know all of that?”

    “It will make it much more efficient for my attorney to do his job when he files a lawsuit against all related parties in this case.”

    She replied (VERY quickly), “Just wait here a minute and let me check something, then I’ll be back to give you more information.”

    I waited patiently in the hall, and within ten minutes she was back and said she had the approval for my husband to stay until he was off the morphine and his BP was stable. He ended up staying 7 nights instead of 3.

    Grrrrr!!!!

    • Joanie:
      I am so sorry that you had to go through all of that, but I am so thrilled you shared that with us. That story really helps. I love how bringing legal action into it changed their tunes in a hurry. I know you sharing that with us will really help people. THANK YOU!

  • Oh and it’s not just Medicare patients. It’s like they have a script and they follow it to the T. If anything goes different than the script they don’t know how to handle it. No off-scripting allowed.

    My husband had out-patient surgery a while back. After he was in recovery the nurse called me back and said my husband was being released and I could go help him get dressed. When she pulled the curtain back, he was still out. I mean out cold. She roused him and handed me his clothes. It took everything I could do to get him dresses. He’s not a little guy.

    She went and got a wheel chair and told me to go get my car and pull it around front and she would bring him to the car.

    When we all met up out front, He tried to get out of the wheel chair and was all wobbly and stumbling around and moaning something horribly. She looked at me and said (and I am NOT making this up), “Is he going to be okay?”

    What the HELL? The NURSE not an aid, not a candy striper, a freaking RN was asking me if my husband was going to be okay.

    • Tricia:
      This is awful. I can’t believe how nicely you handled it. I would have flipped out. I think a couple of people on my mom’s floor were ready to get rid of me! :)

  • It’s amazing that Medicare didn’t make your mom or dad actually get on the phone. I try to do the legwork and phone calls with our kids’ claims–and even my own claims–and the insurance company won’t allow me to get through b/c the insurance is through my husband. I’m like, “This is for MY care. Don’t I have a right to know what’s going on with MY care?” I have to hand the phone to the hubby so he can clear it up.

    America’s health care system is just so broken. When I worked at a home for pregnant teens, one of the girls would demand to take their baby to the ER in the middle of the night at least ONCE A WEEK. Taxpayers are paying for their benefits. The babies could have easily gone to the clinic in the morning (because it was just a simple cold or allergies), but I think they were 1) looking for something to do to just get out of the house (plus it’s more adventurous in the middle of the night), 2) have no concept of how expensive a trip to the ER is, and 3) they come from families who have been in “the system” so it’s a generational idea to “just go to the ER for anything.” Ack! It makes me mad how misinformed and casual people can be.

    • Spirit Lady:
      I can hear your frustration screaming through the computer, and I don’t blame you at all. That’s why I call it the insurance game. Really, I know my parents are so lucky to have what they have. It’s just frustrating that this game is LUCKY at all. Know what I mean?

  • Ugh what a situation. We’ve not had to battle the insurance stuff with my mom yet, but as my son goes through medical care, I wonder if we have those battles to face yet. With the expenses racking up, I’m quite sure the insurance will want to deny something!

  • Advocating has become a part of caregiving. As a social worker, I was pretty familiar with the process. Yet in taking care of my mom for several years, I have found it to be a more regular part–probably a combination of her failing health and the increasing complexity of the insurance hoo ha. I’m so sorry you had this experience, but I’m glad you were able to put your experience to use and share what you learned in your very valuable advice.

    • Thanks, Judy. Taking care of our moms is better than the alternative in my book, but I just wish sometimes it was easier to deal with all the red tape. I can imagine since you know the ends and outs of this from the professional side–that sometimes having too much information can make you even more skeptical that it will all work out. Luckily for my mom–it did! Thanks for stopping by. :)

So, what do you think?