Denied rehab stay by Medicare advantage insurance, post hip replacement surgery. Others have this experience? What did you do?
My husband recently had to have unplanned hip replacement after fracturing his upper femur due to a fall. Hospital referred him to a facility for inpt rehab and the pre certification was denied by our Medicare advantage insurance company. Hospital and receiving facilty were both astounded at the denial, as hubby has other complicating factors potentially impacting rehab, so it's not a simple case. We are of course appealing the denial. In the meantime we did manage to get him transferred to a SNF (skilled nursing facility) where he's making great progress. We are "self pay", but fortunate to have long term care insurance insurance that is willing to pay for the stay though not for the therapy services. If successful in our appeal, the Medicare advantage plan will pay retroactively to admission date. We are more fortunate than others in having the LTC insurance, but we hate to have to use it when Medicare should be paying. I suspect if we had traditional Medicare they would not have denied the rehab stay.
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Hopefully, someone on the forum uses a Medicare Advantage. My supplimental is thru my DHs employer. Never have these problems.
We had straight Medicare ( with a supplement) and after months of calling and questioning, I finally found that one person who was willing to care enough to look back at the records and was astute enough to pinpoint the error. My advice to everyone.....due diligence does pay off, but you need to be your own advocate.
So I wound up putting my mother in a rehab unfit for a dog because Medicare PPO plan sucks, basically. Took me 5 days to get her out of there and into a good place and that's how I found out about all of this Medicare nonsense.
I wonder if your plan was rejecting the FACILITY and not the need for rehab?
rehab coverage seems to be glossed over in all the plans I’ve looked at. I wish I knew which plans have in detail what’s covered in rehab.
The groundwork is relentless....to protect yourself in the future my advice is to check out the supplemental F plan. You can enroll now at a cost of about $235 per month. Covers mostly everything and no need for referrals.....and you are covered in all 50 states. Plus all major insurance carriers have the exact same plan. We learned the hard way....I am not a solicitor for the insurance industry.....just a graduate from the school of hard knocks.
Good luck to you and I hope this is just a hiccup that will resolve itself and you will receive full reimbursement. Getting proper medical treatment should not be this hard......especially when you are under enough stress to begin with.
You who have your existing F can roll yours over but no new ones.
oh so not happy as going Original with an F was just going to be what we did when hubs retired. We’re still on his employers “Cadillac” plan (& @ $570 biweekly for family coverage & his insurance it should be a Ferrari) but now I need to research just wtf to do upon retirement since no F.
I think the Plan C is going this route for new 2020 enrollment too.
I found the cost of the MediGap (supplement) policies to be quite high! Plus you have to pay for a Part D drug plan and still pay the monthly Social Security part (that is automatically deducted). This adds up! My Advantage Plan includes part D. My mother has a different carrier for her Advantage Plan and it is amazing all the things it covers! Neither of us have had problems other than the denial of inpatient rehab which I appealed and it was granted.
Its the structure of “Advantage” plans that are the inherent problems.
The whole premise of Advantage is to limit you to a narrow network with an even narrower group of providers. So if the care you need doesn’t fall within basically a subset of a set, just too bad. You pay out of network or you get wage garnishment or go bankrupt or you impoverish yourself to be a dual on Medicaid/Medicare. What’s especially galling is that CMS underwrites a good bit of Advantage Plans. They siphon off $ from original MediCARE for Advantage. All done under the illusion of creating a more “choices for consumers” via underwriting insurers who trot out Advantage plans; and taking $ away from Original MediCARE. What a steaming load.
Single Payor needs to happen in the US. Whether it’s MediCARE for all or the Kaiser model (Alva oh lucky you!) of HMO systems.
Second-without knowing if he satisfied Medicare’s three day hospital inpatient requirement, we can’t know if he qualified for rehab facility.
Third-Medicare is moving toward outpatient joint replacements, same day discharge, or next day. They are doing this partly to prevent joint replacement patients from qualifying for rehab care post-hospital discharge. Virtually nobody with hip surgery qualifies for rehab now. Just because the model patient without comorbidities May do well with outpatient joint surgery, we all are now expected to recover just as quickly.
Fourth-As others have said, if a person is on a Medicare Advantage Plan, if one can get through underwriting, and if the premiums are affordable, Original Medicare with a supplement, Plan G, is best option, for getting needed care, with all the Advantage Plan restrictions.
You say Medicare PPO, not HMO, correct? You will probably find, as your husband ages, most seniors tend to get sicker and need more care, not less. Insurance companies are in the business of making profit, whether HMO or PPO, and its a powerful incentive to deny as many services as they can get away with. We said good riddance to the south FL Medicare Advantage Plan HMO Humana, when we moved to another state. Both back on original Medicare. We don’t have all the games with insurer denying care now. We are receiving proper medical care, and the screening tests for our various medical needs, plus the accepted medical treatments we weren’t receiving on the Advantage Plan. Strongly urge changing to Original Medicare if you can.
You clearly believe a lot of political scare-talk about Single Payer.
I do not. Nor does most of the rest of the First World, where no one navigates for-profit obstacles or suffers bankruptcy because of medical situations.
Please note where the problems are coming from when the for-profits (Medicare Advantage) are permitted into the government-run nonprofit arena (Medicare),
To address a few of the questions raised by helpful posters: (1) This was not a planned or elective hip replacement surgery. It was necessitated by a fall that resulted in broken femur, near the head. Surgeon said it was a displaced fracture. Not a total hip replacement, "just" the head of the femur. (2) My husband was admitted to the hospital from emergency room and had to wait a day before surgery because he was on a blood thinner. He was in the hospital over the 3 days required by Medicare to be eligible for rehab. In fact, he was in there several extra days because of the Aetna denial. He has other complicating medical factors that already affect his balance and walking, so we were sure he ought to be elgible for rehab. stay medically as well. (3) We had no choice in having this advantage plan as my husband's employer has contracted to put all their retirees on it. The employer heavily subsidizes the employee's monthly premium, and dependents have a very reasonable monthly premium. Between two of us, we are paying only slighty more than half of what our brother in law pays for just himself on a Medicare supplement plan (United Healthcare). Annual deductible is $300 each, and there's a decent cap on annual out of pocket payments. Prescription (Part D) benefits are included.
I've learned a lot in reading the responses, which I think may be helpful for others as well. Thanks all.
I learned this the hard way - now I make them recheck anytime a charge is refused.
frankly, it is super cheap premiums because it delivers very little actual service. Medicare is pushing this hard this year...but...avoid advantage. Their goal is to pay for little to nothing. The internet is rife with the huge number of people denied health service because they have advantage.
you can change to any of the medigap plans anytime...but, you will have to go through underwriting to join a different plan. Check it out.
meanwhile, see if you can find a rehab that is in the PPO for you Medicare advantage plan.
My dad is now with blue shield and we have not had problems with them. I think one reason for this is because the doctor at the memory care facility where he lives is also the doctor on his hmo plan that he is on so super convenient to have him come to my dad. If this were not the case I would not have my dad on an advantage plan.
During this Open Enrollment period, consider moving his coverage to a standard Medicare Supplement Plan. It will cost you more in premiums but it will give you much more in choices and services.
I used a broker that was able to give me a booklet that showed me exactly how the coverage compared from one plan to the next. It was still complicated but it was massively simplified.
I tell everyone to find a Medicare specialist insurance broker.
Not that I could tell you anything, the clever lady you are, but I wanted to share my experience.
The delays and outright withholding of medical care under the Medicare Humana Dvantage Plan in south FL nearly cost both of us our lives, several times. Things like delaying my spouse’s fully blocked carotid artery repair surgery a full five months, trying to not pay for his surgery, waiting for him toile first. Then there was their refusal to order and pay for the pulmonary function tests and overnight oximetry testing for my lung disease, knowing they would have to pay for oxygen for me if they allowed the routine testing that all persons with interstitial lung disease routinely are monitored with. It took almost a year fighting, complaints, appeals, sending copies of the American Respiratory Society recommendations to the HMO PCP, to document I was not receiving industry standard care for persons with lung disease. Then there was my skin cancer, Humana tried to not approve MOHS skin cancer surgery on my face, even though it is industry standard. The HMO doctor kept refusing to make the referral, insisting since I wasn’t a model or movie star, any skin doctor could carve on my face, and to heck with having a cosmetically acceptable surgery on my face. Then there was the years of Humana not performing the yearly low dose CT chest scans on my husband, recommended for high risk persons with history of heavy smoking. It had been their recommended screening for nearly a decade, yet Humana was skipping the screening. When we got here, moved to GA a year and a half ago, moved us back to original Medicare. He got the low dose CT scan of his chest, and sure enough he had lung cancer.
Bottom line is this. If you are willing to be under-treated, have high risk medical conditions and screenings ignored, willing to risk death, by all means, sign up for an Advantage Plan. Don’t say you weren’t warned. For me and mine, even if the company paid for their choice of a Medicare plan, I’d be paying out of my own pocket and pay for the original Medicare plan B, plus a supplement, to prevent careless decisions compromising life, via an HMO or PPO.
Wow! I did not know one could not move from and Advantage Plan to a regular Medigap Plan. Ever? Did your agent maybe just mean you could not change plans between enrollment periods? I thought you could make a new choice of any kind during Open Enrollment.
To newbiewife:
Not sure if you have been able to make headway on your appeal, but you are presenting an example to all of one of the downsides of Advantage Plans. Regular Medicare/Medigap typically pays for 30 days of rehab. At least that was my own experience. Medicare/Medigap then continued to pay for in home PT and OT visits until I was permitted to drive myself to outpatient Rehab which was also paid for by Medicare/Medigap.
Good Luck!
Whenever asked, I always recommend Original Medicare plus a supplement. It’s the rare person who gets healthier in old age. As we become sicker, take more meds, have multiple diseases, the Advantage Plans lose their attractiveness, with increasing copays for more visits, more tests, more hospitalizations. And, the risks of managed care plans undertreating serious medical conditions is very real. Sometimes they simply refuse care, even when such care is standard for the medical condition.
Please, everyone know what you are buying. There are so many stories here on the forum of how Advantage Plans fall short when it comes to providing benefits.
Don't be tempted by retired athletes making excited promises on TV. These plans are a great revenue source for the companies that sell them, but they Take Advantage of the consumer.