Tag Archives: Medical

I see….no wait, I don’t see……

Last week I took my friend, Lisa, to the eye doctor. This is the Scheie Eye Institute, a very prestigious hospital dedicated to eye care.

We’ve been there many times over the last five years. Our last visit was six months ago and now we were back for a follow-up visit. But something was new.

When we arrived at the Institute, as usual, we went to the front desk.  In the past, the front desk checked you in and then you waited to go to an attendant at a numbered station to confirm your insurance, appointment time and any other preliminary questions.

As we approached the front desk on this day, we were told to immediately go over to the standing computer terminals and check ourselves in.

Now the average age of the patients in this rather expansive waiting room seemed to be about 79 years old. I have no doubt that the senior community has many computer savvy members, but not everyone can adjust to any computer that is thrown in front of them.  As one who continues to discover that ‘user friendly’ and ‘intuitive’ are really just adjectives for “get me a 12 year-old over here, stat!”, I was certain that many of these patients were struggling with this new set-up.

Add to that,these computers were at standing stations. I would say at least in an unscientific review of the crowd…. and by that I mean looking at them,  half of the patients were in wheelchairs or using canes or walkers. Standing at a computer terminal would be, at the very least, uncomfortable, at most, impossible.

One more thing.

You may recall this is the Scheie Eye Institute. So……this is a place where people go who are having trouble seeing.  You know, eye patches, eye surgery, eye pain, eye problems.

Based on my knowledge of the scientific method, which I learned from my kids when they had to study fourth grade science, this new system may experience a few glitches.

Hmm. Something's Fishy!
Hmm. Something’s Fishy!

I will say this, Lisa and I were laughing hysterically for hours, even on the way home when we just kept saying but it’s the Scheie Eye Institute!

That’s all it took to make us giggle, ’cause………….

“You Just Have to Laugh…….”

©2016 Cathy Sikorski

Just searching for approval….not PRE-approval

I have been so lucky with my brother-in-law, L this  past year. He has been pretty healthy for a guy with MS and relegated to a power wheel chair. The year before he was very sick off and on and required boat loads of my time. But this year, he has just been doing remarkably well, which led me into this complacent place of thinking all is well in the medical world….at least with L.

And actually, he’s fine–ish. But we are now in a push to get some testing and medical work done before the end of the year. And I just forgot how to do things, and how things would be done to me.

On Monday, L needs an ultrasound to check a worrisome kidney cyst. Okay,  I set up the test at the correct hospital and the correct facility of the hospital. His Medicare insurance requires him to go to certain facilities. Sometimes the ordering physician knows that and sometimes he doesn’t. But after 10 years, I KNOW it and so I set up as many of these tests without their “help”, so we don’t have insurance issues in the future.

I make sure the test is between his breakfast and his dinner, because even though he’s gained at least 40 pounds in the last three years, he gets really cranky if he misses a meal. I get that….it’s part social, part his inalienable right, and part “I’m hungry!!”. Okay, no sweat.

I call the ambulance transport and set up transport to the facility and the eventual doctor’s appointment to discuss the results of the test. And I even make sure the blood work is scheduled to be done at his apartment as a “home draw”, which requires a request to the lab directly from the doctor’s office, because I am not PERMITTED to ask the lab to come to his apartment, since  he is wheelchair bound and has no  transportation….ONLY the doctor can do that. (who of course, doesn’t ever remember that and so must be reminded by me, and then the lab calls me to make sure they can come at a convenient time…UGH does this really make ANY SENSE TO ANYONE????)

And then I realize, three days later, and three days before the test. Oh crap, I didn’t get PRE-CERTIFICATION for the ambulance, which must be a gurney and not a wheel chair transport  (which we will discuss another day) because he must be put on a table for an ultrasound and he cannot get out of the chair and onto a table by himself.

So…………….I call for the pre-certification:

“Hello, I’m calling for a pre-certification.” (This of course, after pushing 42 buttons and getting disconnected, and being asked at least four times: “are you calling for a pre-certification?)

“Okay, can I have the name of the member, his ID number, his date of birth, his first born.”.(okay they didn’t ask for that, but they might as well have)

And after I get it all squared away, I think…

“Now, you will have to have the ambulance transport company call us to request that.”

“Well, I’ve tried that before. First of all, they won’t do that. Second, in order to request this you need the prescription, the diagnosis code and the physician’s name, am I correct?”

“Well, yes, so that we can approve that it is medically necessary for him to have transport.”

“Well, the ambulance company does not have the prescription, I do. And furthermore, I wouldn’t give it to them, nor do they want all this medical information on my brother-in-law. Not to mention that I’m pretty sure it would violate like 100 kinds of HIPPA laws to be passing around his diagnosis and doctor names and medical test information, don’t ya’ think?”

“Umm, well………Can you hold for just a second?” the nice lady at the insurance company says to me (the mean lady trying to get ambulance transport for the hundredth time with the same argument for the past three years)

“Okay,” she says as she comes back on the line, “can you give me all of that prescription information?”

“Of course,” I say. NOW, I hope against hope that we are really almost there.

“Well,” she says, “that will do it!” Very bright and chipper I might add!

“Oh, no, no, no,” says the voice of experience, “I need an authorization number,” knowing full well that the ambulance company won’t transport without it.

“Well, okay, I can give that to you, but this has to go to our medical team to determine if it’s approved. You will get a confirmation in 2 to 3 days.”

“Okay,” I say, “just give me the number.”

Because I know their dirty little secret. They will approve this BY MAIL in a week, if I’m lucky. But I will not cancel the test, because they will put on their approval that the transport is approved for the day of the test, effectively making it retroactive. But if  I wait for pre-approval, I will magically have to know when the approval will come in to schedule the test since they only approve a specific date. Don’t overthink it. It’s complicated and stupid. I’ve played this game so many times, I just know how to do it. Trust me.


You just have to Laugh……………………..

Cathy Sikorski

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Never call an ambulance if you’re old…..Part 2

I think I have spent about $5,000  ( at least in legal time and photocopying) trying  NOT to pay an ambulance bill. I began this tale as one of my first blogs, Do you really need an Ambulance? I think not. I related that my dear 95 year-old mother-in-law was found in pain in her assisted living facility, and the staff correctly called an ambulance. Her pain was evident, so even though she suffered from dementia, which was documented, the ambulance drivers decided to take her to the hospital.

For over a year now, I have been fighting with Medicare to pay this bill. I have told the Ambulance Company, I will not pay this bill, as there is no way my mother-in-law could have made the decision to go to the hospital, let alone  CALL for an ambulance. I do not wish to leave these hard working emergency first responders without pay. However, there has to be some manner in which they can support the patient when the first responders make a medical call, that requires an ambulance.

My mother-in-law does not drive. She has never driven. She has never had a car. In an assisted living facility, she has no transportation to go anywhere without it being directed by someone else. The facility is also doing the right thing by calling for an ambulance for a client who seems to need medical help.

Okay, so we’ve established that everyone who actually PARTICIPATED in this trip to the hospital made a rational and correct decision. The only people who don’t agree with this is Medicare and it’s not even Medicare. It’s a company called CMS, an independent contractor, who assesses whether the claim should be paid. So I send 22 pages of documentation with a letter of explanation telling this independent contractor why they should pay this bill.

The first denial is because this darling old lady really didn’t need to go to the hospital. They found nothing wrong with her and sent her home. Yep…..that’s absolutely true. But, I persist with an appeal.

The SECOND DENIAL is because I have NO AUTHORITY to appeal. I call to clarify this.

” If you would like to leave a message, please leave the appeal number, the claimant’s social security number, the date of service and the provider for which you are appealing. Please leave a phone number and we will return your call.”


They do call me back, and I explain that I am holding in my hand the appointment of representative form that gives me authority to talk to them AND to APPEAL.

“O well, sometimes Medicare doesn’t send us all the paper work in the file so you need to send it to us again.”

I grind my teeth. Call the ambulance company AGAIN to reply to the bill they have sent ME again, and tell them I am still appealing.

The THIRD DENIAL comes because they still didn’t get my paper work. I call them again and they say….”oops”….and ask me to send it again. I ask the representative to explain to me how I will know if they get it…she says:

“Well you might get a notice that we received it…..wait, no, no I don’t think you will.”

Yesterday, I got the ambulance collection agency notice. They are going to sue my mother-in-law, which I kind of want to let them, because she died.

But I leave a message for the independent contractor, who calls me when I am in a meeting and can’t answer the phone. AND THE MESSAGE IS:

“This appeal was dismissed twice for failure to have the proper paper work to authorize you to appeal.”

I am not fing kidding. I’m not.

I was just going to pay the $797.20 bill. I mean they are just wearing me down to the nub. But I decided to give it one more try. I’m waiting for the return call.

To be continued……

And you really, really do…….

Just have to laugh….

Cathy Sikorski