Tag Archives: Medicare

The best laid plans……………

I have literally spent more than 10 hours (probably more like 20) trying to figure out what new Medicare insurance plan to choose for my brother-in-law. He currently pays for his insurance through his former employer. They have chosen to get out of the business of supplying insurance carriers for their retirees, so by the end of May, all retirees have to choose a new Medicare Plan.

When I first got the booklet for this, I was sure it was a scam. These Medicare Insurance companies that ‘help’ you choose a plan are suspect to me. But I called his employer. All I wanted to know is if it was a scam. I didn’t want any specific information about my BIL or his account as a retiree.

I had to jump through a billion hoops (this is not included in the 10 hours above), prove my POA status, give them all my BIL’s vital statistics and THEN, they needed a PIN number. Somehow, the one I had was expired. So I asked for a new PIN which had to be snail-mailed to me.  I finally convinced the representative to at least just tell me if the Medicare company was a scam. She relented and said no, it was not a scam….but that was ALL she was going to tell me until I got my new pin number.

business-19156_1280Already, I’m exhausted. But I push forward. I go on the website. I enter every medication, every doctor and all the vital stats. Two hours later, they give me a proposal of 18 Medigap policies to compare with 26 Medicare Advantage policies and 20 Medicare Part D Prescription Drug Plans to add to the comparison. For those of you who may struggle with math, that is 64 plans I should look at to compare and contrast to choose the best one for my BIL. And choose, I must, because as of May 31, 2015, they will automatically cancel his current insurance.

This got me thinking, What if this information was sent to my BIL and he had no one to help him wade through it? First of all, it’s a website. There are  in fact, still some people, many of the  Medicare Age Variety who are not computer savvy, hell, who don’t even have a computer. Yes, snobby Medicare helpers, everyone on the planet doesn’t have a computer. Now my BIL is very computer savvy, but he can’t really type anymore.
And he doesn’t really read anymore, because comprehension and retention elude him often. And he for sure, isn’t going to decide to read through Medicare plans as a fun hobby.

I am considered an expert in this field of Elder Law issues, including Medicare Insurance. And I completely UNDERSTAND what I’m reading. I am expected to find the nuances and loopholes in 64 different plans that best serves my BIL. And even I find this daunting.

And once I choose I am in a quandary. This special circumstance where they are cancelling his policy is considered an opportunity for open enrollment with no underwriting. In other words, nobody is looking at the fact that he has a myriad of health issues which would kick him out of any health insurance otherwise. So once I’m there, I’m never going to be able to leave without a problem.

My point is this. I’m exhausted. My severly disabled BIL, on his own would have probably missed this whole need to do this and be without health insurance. How many retirees from this major Fortune 500 company are struggling with this project? Even though it’s a great website and the advisors are pretty good at their job…I KNOW WHAT I’M DOING, AND IT’S STRESSING ME OUT.  The choosing is a nightmare.

I know, three months from now I’m going to hear from the new insurance company that Oh that’s not covered, oh that has a huge copay, oh he can’t have that NEW drug that he wasn’t on when you chose this plan.

The only thing that makes me laugh now is laughter of relief. But don’t worry, I’m plotting revenge somehow and you will be the first to know!

“You just have to Laugh…..”

© 2015 Cathy Sikorski

Good Luck with that Appeal…….

This  is a Medicare Card. Everyone’s Medicare Number is their Social Security Number.

Conversation with Medicare Appeal Board:

“Do you have the Social Security Number of the person who is appealing?”

“Sorry, I don’t.”

“That’s okay. Do you have their Medicare Number instead?”

I rest my case.

“You Just have to Laugh…..”

©2015 Cathy Sikorski

Best Notify My Next of Kin…This Wheel Shall Explode….Absolutley Fabulous

The frustration level of caregiving is equal to the dropping temperatures here on the East Coast, which is at a 100 year low.  Pretty sure that’s true.

Finally after spending 6 months in rehab, my brother-in-law was finally home, healthy and enjoying his meals in the dining room with his best pals. Then the flu hit his facility. On Christmas.  But five days in the hospital with the flu, double pneumonia and a urinary tract infection did not keep  him down. Home on New Year’s Eve, he was ready to get back to his normal life.

When he, his neighbors and his caregivers all noticed that he was precariously listing to the right, they called me.

Now this wheelchair has been a problem for several months. A new set of footrests were installed and ever since then, the wheels get stripped. After the second time this happened, I told the repair people to really look at the problem.  The footrests were major culprits and needed a good talking to.

Here we were again only 60 days after new wheels were put on the chair. My brother-in-law looked like he was practicing for a circus act, as he sped down the hallway with his hair blowing in the breeze at a 45 degree angle.

When his caregivers called me, on Sunday, I was firmly ensconced in a charming little Italian restaurant 150 miles away in NYC. Of course, it’s adorable that they think I can actually fix the wheelchair.  I would have to have extra wheels, a special screwdriver, and actual mechanical knowledge. No wonder I have a God complex.

Monday, bright and early I call for repair assistance. I beg. I plead. I offer candy, money and my first born, whatever it takes to get this chair fixed ASAP, since he just got back to a semblance of a real life. What usually requires two weeks, will take two days. Okay, we can live with that.

Two days later, I arrive at my brother-in-law’s apartment for the 10:30 AM appointment. I’m psyched. Chair will be fixed. Man can get in chair and have meals with friends, all will be well in the universe.

10:30 comes and goes.

11:00 comes and goes.

“Hello, wheelchair repair guy, where are you?”

“He’s just a bit late,” they tell me.

11:30 his caregivers arrive to get him dressed to gently place him in his newly fixed chair. Except that it’s not.

12:00 comes and goes.

I have to call again. Why would they call me? I’ve only called them 10 times in the last 48 hours. It’s not like they have my phone number or know that I am waiting for them.

“Hello, wheelchair repair guy, where are you?”

“He got caught up at his last job, he will be there as his last appointment of the day. Sorry, i hope that’s okay.”

Sure. I only have to now order his meals to be delivered to his room, if it’s not too late. I need to reschedule all the caregivers because their duties will now change, since he is in bed and can’t get in his chair. I will have to go to the dining room and tell his dining buddies that they don’t have to set up his place, his tea, and his special condiments like they do every day because they are kind and amazing. But sure, no problem, you just show up when it works for you.

What I say is, “okay, just get it fixed, today.”

Miracle of miracles, I come back early in the evening to find BOTH wheels repaired, the foot rests changed and the chair ready to go. Too late to get my brother-in-law in his chair. But he says, “hallelujah” when I tell him he will be out and about starting with breakfast tomorrow.

On my way to a business appointment the next morning, I’m feeling quite smug as I know my brother-in-law is already at breakfast and I got the chair fixed in 2 days!

My phone rings. I answer with a happy lilt in my voice.

“Hello?”

“Hi Cathy? This is the caregivers. Larry doesn’t feel well. He refuses to get in his chair. He has a temp and should probably go to the ER.”

You just have to Laugh………….

©2015 CathySikorski

I always tell the truth. Even when I lie……Al Pacino

There is a Medicare rule that requires your Part D (which is prescriptions only) provider to now call you before they send out your medications.

Many of these Part D providers also require, or at least push for you, the patient, to purchase your medications through the mail. The insurance provider wants you to have your doctor order these medications directly from them and then the magical pharmacy in the sky sends the medications to your home.

This process has its ups and downs. On the up side, your medications are delivered directly to your door. For many a senior, ill person, or caregiver, this is a blessing. Nothing is more delightful than not having to go to the pharmacy a million times a month for meds that run out at random intervals.

However, often our elder parents, aunts, and friends are frustrated by their inability to have that paper prescription in their hot little hands, take it to Phil, the Pharmacist, and go home knowing they have the correct meds as confirmed by Phil, and they don’t have to wait days or weeks to see the meds they need.

Now that Medicare has added this ‘protective’ provision that your insurance company must call you on the phone and confirm that you or your doctor ordered this medication, that you actually want the medication and that you wish it to be sent to you in a 90 day supply, another fun-filled element has been added to the mix.

So for me, it goes like this.

My brother-in-law struggles a bit with the phone, pays no attention to his meds anyway, and has for 5 years, relinquished any responsibility for anything. So, I leave a message at my brother-in-law’s doctor’s office requesting they order the medication.

I get 2 or 3 emails from the Part D insurance company confirming that a mysterious prescription has been ordered. They can’t put the name of the drug in the email, so I have to go to the Part D website to see if the correct drug has been ordered. My brother-in-law takes 40 pills a day. So I have to wade through the list to make sure all is correct.

Then Part D Insurance Company calls you on the phone. I never know when this call is coming. If I  miss the call, I put the process behind until I can respond. Now, for all of you who may need acting lessons in the future, I was a theater major in college for a bit, and I will be giving lessons. Now.

When the caller asks you if you are your brother-in-law, drop your voice three octaves and mumble a reply that sounds something like, “Yus.” You’re only talking to a machine, never a real person. Every other question, as his Power of Attorney, I have answered a million times, so I have the answers. But remember mumbling and voice alteration are your friends.

You will be pleased with the results when they conclude the call telling you your drugs are on the way! Just in case you don’t remember this conversation, they send you yet another 2 or 3 emails to confirm that the mysterious drugs, whose names shall not be mentioned in an email, will be delivered shortly.

You’re welcome, and remember all my caregiving thespians….

“You just have to Laugh…..” but don’t do it while mumbling and dropping your voice a few octaves.

©2014 Cathy Sikorski

And the Winner is…………….

As every caregiver knows, I have been frustrated so often by insurance companies and physicians offices that I, well…started a blog.

If  you’ve read my : Never call an ambulance if  you’re old…..Part 2  and  Ambulance…”part trois”….., you know that one of Medicare‘s absurd rules is how to transport the infirm. They will pay for transport from facility to facility, but they will not pay for transport from your home to any medical appointment or hospital test (with certain exceptions). So, if you are completely wheel chair bound, like my brother-in-law, have no use of your legs, and your doctor orders a CAT Scan or MRI, or even the lowly X-ray, you:

A.  Can’t get there

B.  Can’t get ON the table when you get there

C.  Better have a bucket of cash stowed somewhere to pay for private transport

After days, weeks and months of figuring out the rules, and hacking at the system. I found that if my brother-in-law could be transported upright, so that he didn’t have to get out of the wheelchair, he would have to make all the arrangements with the ambulance company and pay for it himself.

If, however, he needed to get on to a medical table for any kind of test or examination AND the test or examination was at a hospital, then Medicare would pay for the ambulance and I would still have to make all the arrangements for transport.

This is how I found that out.

Medicare denied payment of a transport for a CAT scan. I followed all the rules, contacted all the right people. Got all the pre-certs, the approval numbers and the referrals. But since I had already scheduled the scan, I just used the information the insurance company gave me and had the test done.

Several weeks later, I get the denial for payment. I made a thousand phone calls, appealed the decision, twice, and was still denied as transport not an emergency or medically necessary.

Now I had to appeal to an Administrative Law Judge. This law degree I have and over 15 years of practice in Elder Law came in handy. I jump in with both feet and file the appeal. But because I’ve been around this block many times with many people, I know that a simple paper appeal will not work. Short of asking the ALJ to come to my brother-in-law’s apartment and see how the hired caregivers get him ready for the day, I’m pretty sure the information I would send would not shift the decision.

Yay….social media…..Yay….youtube.

I get up very early in the morning and with my brother-in-law’s approval, I take that amazing little iPhone I have and make a movie of the two caregivers dressing him, washing him, lifting him out of his bed and into his wheelchair, combing his hair,  helping him brush his teeth and shave, and giving him a nice pat on the head to have a good day.

I make a copy of the video, put it on a CD (yeah the Medicare appeal system isn’t that tech savvy that I could upload it), mail it to the judge, and wait.

Lo and behold after 3 hearing cancellations by the insurance company, I get a phone call from the judge’s office saying that the insurance company has decided to pay the claim and there would be no hearing.

I take a bow and accept my Oscar for best performance by  a caregiver.

You just have to Laugh……

Cathy Sikorski

Um….yeah…..not paying that….

You think when your caregiving ends….well, your caregiving ends. But not so, intrepid caregivers. I’m now steeped in estate work and it, too has it’s unbelievable encounters. I have to call billing department after billing department to make certain that a bill is legitimate before I concede to pay. And each billing experience makes the last one look like child’s play.

Billing Experience Number One (really probably number 157)

“Hello? I have a billing question. Can you help me with that?”

“Sure.”

“What information do you need?”

” How about do you have a name and birthdate?”

“Why yes, yes I do.” And do I give her all the necessary information to retrieve the bill for my mother-in-law.

“My question is, this bill seems to have been processed by all her insurance carriers, and so there should be no balance due, and I know that she has also met her deductible.”

“Well, there is still a balance due after that.”

“No, I don’t think so. I’m pretty sure that according to the laws in Pennsylvania, if someone is on Medicare and they have a Medigap policy and both insurances have paid AND the patient has met their deductible that you must accept that as payment in full.”

“One moment, please.”

Oh boy, Muzak.

She returns pretty quickly, which in and of itself makes me happy.

“Well, ok, then. There is no balance due, but we didn’t have in our records that she was on Medicare.”

“Really? Because you just asked me to identify her by her birthdate, which is 1916, which makes her 97 years old AND you are showing on your bill that Medicare made a payment, just sayin’…”

“Well……”

And she hung up.

Billing Experience Number 2 (Actually not even 157, more like 210 by now)

“Hello. I have a billing question. Can you help me with that?”

” I will transfer you to billing.”

“Hello, I have a billing question. What information do you need?”

“Sorry ma’am this isn’t billing. Let me transfer you.”

“Hello, I have a billing question. What information do you  need?”

“Can you hold a moment?”

Of course, I don’t get to answer that question. I just get more Motley Crue Muzak.

“How can I help you?”

“I need to know if this bill for Aunt J is final?”

“Well, let me see…..hmmmm…..no, it looks like there is another bill with an additional balance.”

“Well, I’m sorry to tell you that there are no funds to pay this bill or any future bills. There will be no estate and the patient was visiting from Australia.”

“What? Australia? I don’t understand.”

Really? I’m thinking…..what’s not to understand. That seems pretty clear to me, but OK, I’ll just lather, rinse and repeat.

“Well, I’m sorry to tell you that there are no funds to pay this bill or any future bills. There will be no estate and the patient was visiting from Australia.”

“Um…ok…so could you send us a letter to that effect with a death certificate?”

“Sure. I would be delighted to do that.”

So far I’ve had to send that letter and death certificate 11 times. Do you think they would send me anything for free?

You just have to Laugh……

Cathy Sikorski

Ambulance…”part trois”…..

Just a very brief update…..

I am taking my cell phone with me absolutely EVERYWHERE. I am NOT going to miss the call again from the Medicare independent contractor, CMS. Because, as you know, if you miss the call, you can NEVER talk to anyone. Out of sheer exhaustion one afternoon this week, I go to lie down, just for 20 minutes or so, and put that cell phone under my pillow…like shotgun….I am NOT going to even think about RESTING without that ordnance by my side.

Lo and behold, that cell phone vibrates under my head like a 25 cent bed in a cheap motel. Of course, I’m in  a dead-to-the-world sleep, but, as a caregiver, I am so committed to alertness that any signal of distress, alarm, help, or hunger has me jumping up like a thoroughbred at a starting gate.

“Hello?  Hello?” I’m yelling into the phone like it’s a crank phone with a party line.

“Hello. may I speak to Cathy?” says the other line.

“Yes, this is me,”I say.

“This is Rebecca at CMS, the independent contractor for Medicare Appeals!” (you may wonder why I always put that in italics. It is because they use that phrase like it is a papal dispensation for everything that is about to follow)

So I carefully and slowly and without rancor(really I try as hard as I can to keep under control, “more flies with honey than with vinegar” theory) explain to Rebecca that I have sent them the necessary documents for my AUTHORITY for this appeal, three times.

( n.b.(which means ‘note well’) they readily admit they have all the documents for the ACTUAL appeal, they just claim to not possess the documents needed for ME to appeal. And you wonder why caregivers sometimes pretend to be 96 year-old men just to get something accomplished. I digress……)

To her credit, Rebecca stays on the line with me for 10 minutes or so and by listening to me  as I document every date and page I have sent them, and looking, really looking: EUREKA! She finds ‘my authority’!

“Ok, she says,” now I have to see if it was filed in a timely  manner.”

Since I KNOW it was filed in a timely  manner, I just sit on the other end of the phone with steam coming out of my ears waiting for her to confirm that.

As we wrap it up, she tells me:

“Okay you will get a confirming letter re-opening this appeal from it’s dismissal in about 2 to 3 weeks. Then we will review the appeal and send a notice of our decision.”

“So, just so I understand, since I have to report this to the collection agency,” I say through clenched teeth,”you will let me know you FOUND the paper work I’ve sent you three times and THEN weeks or months from now you will let me know your decision on the appeal?”

“Yes, ma’am, that’s correct.”

“Thanks, Rebecca,”I say as I reach  for the Pinot Grigio and go back to bed.

You just have to laugh……..

Cathy Sikorski

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.”

YOU CANNOT TALK TO ANYONE…..EVER.

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

Walgreens on Main Street…..

This is a continuation of  When UTI does not mean Understanding the Infirm only in the sense that that is why we are now at Walgreens on Main Street.

My dear disabled friend, who braves her brain injury with the utmost courage, must now go to Walgreens on Main Street to acquire her prescriptions. The PA  (Physician’s Assistant) has given her TWO prescriptions to relieve her infection and her discomfort from the UTI (urinary tract infection).

These adventures in medical care are half-day or whole day journeys for her because she must navigate her town by city bus or by walking. And although walking is a very healthy alternative that she often uses, sometimes it is too much for her and she must be at the will of the bus schedule(which for some odd reason changes constantly, because as we all know, people who NEED to use the bus have no problem not knowing when it will come and go, since they can just get on it, like the rest of us get in our cars)

Trekking from the doctor’s office on one side of town to the other, she gets to Walgreens on Main Street and unimaginably, her prescriptions are ready. And I might add here, that the pharmacists at this Walgreens are wonderful. I have been there with her many times and they are accommodating, understanding and extremely willing to help. But sometimes…….

The pharmacist tells my friend that the antibiotic is ready but that the other prescription needs more information from her doctor.

“You need to go back to the doctor’s office and take this form and have them fill it out, because Medicare won’t cover this drug without further explanation from your doctor.”

“But, I just came from there…it will take forever…..”

“Well, the only other thing I can do is send it to your doctor and then send it to Medicare, but then you may have to wait up to a week to get your medicine.”

“But, I don’t drive, and I just can’t get back there today,” says my friend, “it’s just too much, I can’t do it.”

The two of them stare at each other for awhile. Both of them locked in thought, and maybe even trying a “Sheldon’s mind meld” from the Big Bang Theory, to see who will crack first and make this better.

“Isn’t there ANYTHING else we could do?” says my friend, who is rightfully STILL worried about her brain.

“Well,” says the pharmacist, “you could just pay for it.”

So now my friend is thinking: “Okay, I’m on a very fixed income. I have to watch every incidental I pay for because I just don’t have enough money for everything. But I will bite the bullet this month and deprive myself of whatever is necessary to pay this exorbitant drug cost to protect my fragile brain. I know drugs are hundreds of dollars, but I just can not go through this one more day, or wait a week……”

“Okay,” she says with great trepidation,” how much is it?”

“Twenty-three dollars.”

You just have to laugh…….

Cathy Sikorski

No matter where I go….

So I volunteered to be on an advisory board for a Catholic elementary school. I know, I know, REALLY? You need to do more volunteer work? But my really good friend, the principal of the school asked, and whenever she asks me to do something I say yes and have regrets later. But THIS time, I figured it’s about little kids, no elders, no Medicare, no Social Security, no nursing homes. Yay….little kids.

The parish priest leads the first meeting, and after we open with a prayer (and boy do I need all the prayers I can get), he tells this quick story.

“So, I’m a power of attorney for one of our parishioners who is 90 years old.”

Oh MY GOD (i’m thinking) REALLY, SERIOUSLY, THIS CANNOT BE HOW THIS MEETING STARTS.

“AND,” says Father, ” he was rushed to the hospital a few days ago, so of course, the hospital called me right away.  I went over there to make sure everything was fine, and they were going to keep him for a few days and then send him to rehab to one of two possible facilities.”

So I’m thinking: okay, he probably had some problem getting him in to the facility that he wanted. Or the elder parishioner had some unexpected medical condition. Nothing new here. And, by the way, I have not yet confessed to this group what my background is.

Father continues:

“The dear man is in the hospital for three days, and I’m waiting for a call because they have told me that he will likely be moved today or tomorrow. So I’m sort of hanging around, trying to stay close to home in case they call or need me for anything. Finally at 2:30 in the afternoon the nurse contacts me and says:

“Hello, Father?”

“Yes? I have been waiting for your call.”

” Well, I guess we should have called you sooner, like BEFORE we released your parishioner from the hospital.”

“REALEASED HIM???!!!! WHERE DID HE GO? He’s 90! He doesn’t drive and I’m the only one who transports him. WHERE IS HE?????

“Oh, he was transported by ambulance to a rehab center.”

“WHICH ONE…. where did you send him?????”

Poor 90 year-old guy, when he got there, he had no idea where he was, why he was there and what was going on. NOT BECAUSE HE HAS DEMENTIA…..he doesn’t……BECAUSE NO ONE TOLD HIM OR HIS CAREGIVERS.

Yup, true story (and I asked Father if I could put it in my blog and he gave me his blessing …and said yes, too)

You just have to laugh…….

Cathy Sikorski