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.