My mother has cancer lymphoma and paralyzed due to a tumor on her spine broke through many of her vertebrae. She has a success rate of able to walk again and cancer 100% curable. Her insurance is crap. She owes $50,000 from nursing home. United cut her benefits off from some bad reporting now on self pay second appeal. I'm overwhelmed with anxiety...can't sleep or eat...how insurance is not paying I wrote to the white house.
Please help. My mom did not get her affairs in order leaving the burden on me. Too weak while having chemo now. They are kicking her out of the hospital Saturday. Trying to send her home. She needs 2 CNAs at all times.
Ramps to be built, bad access to the house. A hospital bed and much much more. Overwhelmed.
What do we do? She needs PT and skilled nursing.
Before signing any Medicare Advantage Plan it’s so important to read the fine print and the entire policy. If you have a moment, review your mother’s policy including coverage for LTC to get a good basic understanding of what is covered and what is not.
Basic Medicare Advantage plan’s especially with UHC cover the minimal requiring the patient to assume huge deductibles and copays. You may find her needs now are different than what she signed up for. Medicare Advantage plans may pay that monthly Medicare premium & sound great in advertising but not so great when the rubber meets the road. She is stuck having to see their providers and in network services UHC provides.
Unfortunately, be prepared to get nowhere. I hate to be so realistic but this may be true. UHC pays her Medicare B premium and expects in return the member is aware the excess cost will not be paid by UHC. Advantage plan goals are to keep costs down. Of course she’ll be covered but I assure you not completely.
So again read your mothers policy as that dictates coverage. Once you understand the policy’s coverage and their appeal process you *may* stand a chance to fight them.
How long was Mom in LTC? If she had been in just the 100 days, the cost should not have been much more than 12k. I am basing this on $150 a day, which is what my Mom paid a while back. So I am assuming she was in past the 100 days.
My next question is, did the finance office offer to file for Medicaid to cover the cost? When Mom went into rehab I was told exactly what would be out of pocket. I was told if she didn't have the money she could apply for Medicaid. See if Medicaid will cover the 50k
If you need all this for Mom, I would see if she qualifies for Medicaid and place her in LTC.
You may know this but just in case...Medicare only pays 100% the first 20 days, 50% 21 to 100 after that. If within the 100 days the patient has hit a plateau, then Medicare does not pay and patient is discharged. With United, I would appeal their ruling. Supplimentals do not pay total amounts. Mom had United and still paid 150 a day.
If you are using the United Healthcare customer service to file appeals, over the phone, there may be better options for appeals, to give a better chance of winning your appeal. I spent ten years in the health insurance industry, wrote appeals that sometimes became legal documents, going through court, as in lawsuit. Too often the customer service reps in the health insurance company don’t write thorough complaints and appeals.
If you are writing the appeal yourself, since it is a second appeal, I hope you are copying her state department of insurance, plus the lawyer, so that United Healthcare knows you mean business. I also always copied the internist plus the specialist, as a courtesy, so they would know what I was challenging, if the insurance company contacted the doctors. Then send by some type of traceable mail. Too often appeals paperwork never gets proper consideration by insurance company medical director. Or it gets conveniently lost. I learned early on, once you copy the state department of insurance, it gets their attention. It is helpful when your appeal can cite, or quote, some standards of care from one of the medical groups publishing the guidelines. That will open the discussion regarding whether standard of care is being followed. I had to do this with my own home oxygen, when my HMO pressured their Plan doctor’s, internists, to simply not make the referrals needed. It’s unfortunate that insurance companies are especially brutal in denying coverage they should be paying for, with long term care policies especially, being challenged. Their aim is to drag it out until the usually elderly patient has died. Trust me, I worked for the ugly side, insurance company. Their greed motivates them to try and get away with as much as possible. Of course, you will want to get copies of all medical records, to make the most of your appeal.
Example:
I have lung disease. The HMO I previously was in didn’t want to pay for the testing, thoracic society recommended Six minute walk test, overnight oximetry testing, pulmonary function tests, all necessary for proper pulmonary workup. They didn’t want any test results in my record, so if they could deny the testing, they wouldn’t have to pay for oxygen, once the tests proved the need. Those tests show how much functional damage there is, whether or not you need oxygen at night, or with activity, or all the time. I printed out the Thoracic Society guidelines, plus the Six minute walk test protocol, and included it with my appeal, notating the appropriate parts, quoted in my own written appeal. Copied the state department of insurance, plus my internist, and pulmonologist. I was set up for the appropriate testing, in order to document medical need, and qualified under Medicare guidelines for home oxygen. I didn’t have to hire a lawyer, as my well-written appeal to the insurance company medical director forced them to follow recommended lung disease protocol. I am now on oxygen, and no longer dealing with an HMO, thankfully.
Good luck!
God Bless you ❤🙏
Blessings
hgn