Anatomy of a Medicare Appeal

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Anatomy of a Medicare Appeal

Postby CarlaL48 » Wed Aug 21, 2013 8:19 am

It looks like my husband and I are gearing up for a third bout with Medicare. Doing battle with them, however, is not the least bit satisfying because rational thought is not allowed. Where they win the day is in their sheer size and ability to pass the buck long enough to exhaust “we the people.” Pissants all!!!

At issue is my husband Dale’s ride to the hospital on April 1 of this year. I had dialed 9-1-1 after Dale fell for the third time that day, and could no longer help himself off the floor. EMTs arrived at the house, took my husband’s vitals, placed him on a gurney and transported him to the local hospital three miles away. A few weeks later we received a statement for $1267 dollars from the ambulance service provider located in California, who, upon inquiry, informed me that Medicare had denied the claim as “medically unnecessary.”

Since then, I have called Medicare numerous times and each time the dialogue between the rotating staff of Stepford parrots and me goes something like this:

Carla: You do understand that my husband was on the floor unable to get up, don’t you? And yet, you say his trip to the hospital was “medically unnecessary”? Should I have known that? Are lay people now diagnosing health problems?

Bevis/Butthead: Of course not. The EMTs and hospital medical staff make that determination.

Carla: But that’s AFTER the transport has already taken place?

B/B: That is correct.

Carla: Well, if you’re going to penalize Medicare patients after the fact, shouldn’t you at least warn us in advance? Give us the health care equivalent of our Miranda rights?

B/B: We don’t do that.

Carla: Obviously. So tell me, how should my husband have been transported to the hospital?

B/B: He could have taken a taxi, private automobile, wheelchair van or other vehicle.

Carla: But he was on the floor, unable to get up.

B/B: Those are the rules.

Carla: Okay, let’s try this one more time. How could my husband get to, then into any of those other vehicles when he was incapacitated on the floor?

B/B: I don’t know.

Carla: But somehow he was supposed to levitate himself into a different vehicle. By that logic, he could have ridden a horse also – except we don’t have a horse – and HE WAS ON THE FLOOR!

B/B: I know you’re frustrated, but those are the rules.

Carla: Well, change them, or give me someone who can.

B/B: You can appeal. Blah…blah…blah…blah.

Here’s the problem. The government of the people, by the people and for the people has been gasping for air for many years, almost a century, in fact. In its stead is a governmental behemoth that has created burgeoning institutions designed to insinuate themselves into our lives, then take up permanent residence. We the people get stuck with the tab for Uncle Sam’s largesse. But the most gullible among us believe they’re getting a free lunch, so they shrug off a little red tape, a little more infringement on their freedoms, and most of the common sense they ever had.

Uncle’s rules and regulations are so vast and complex as to effectively give the institutions carte blanche to exercise arbitrary judgments on who gets what, when and where. The powers behind the curtain are snake oil salesmen who, in the case of politicians, have lined their pockets by finessing what was intended to be a few years of public service into lifelong careers. (Have you ever counted the number of 70 and 80-year-old fogies in Congress? Meh!) In turn, they insulate themselves with a front line of automatons who spew memorized schlock to the public so they themselves never have to deal with us, the hoi polloi.

At the same time irrational bureaucrats are denying legitimate claims, they’re creating a brouhaha about Medicare fraud. “See it, report it,” they encourage. I’ve no doubt it exists, but who in their right mind thinks ambulances are at the core of the deceit? To the Medicare Gestapo it’s a page out of “Willy Wonka and the Chocolate Factory.” They evidently believe millions of older Americans are plotting to win the golden ticket and get a free ride in an ambulance.

Are they addled? Perhaps they are. Exit Willy Wonka. Enter Forrest Gump in a brown shirt, utterly devoted to his cause, but not having the foggiest notion what the cause is. No sweat. After all, life is a “box of chocolates” and American baby boomers had better get used to it.
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Re: Anatomy of a Medicare Appeal

Postby Robin » Wed Aug 21, 2013 11:21 am

It all defies logic. Have past appeals gotten you anywhere?

In our local area, as I think in many others, you can call the fire department directly and tell them you want a "lift assist" and it's not an emergency. They seem to do this for free, and EMTs aren't called unless there's a problem. This would be for those situations where your husband has fallen, can't get himself up, and you aren't worried that there's a new problem (head bleed, broken bone, etc).
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Re: Anatomy of a Medicare Appeal

Postby CarlaL48 » Wed Aug 21, 2013 11:31 am

The EMT's come with the territory here, Robin, but they will do just a "lift assist" if that's all you need. Our problem is we didn't know what was wrong with Dale on April 1. The fact he couldn't get up made me think he might have had a stroke. It was the EMT's who wanted to take him to the hospital to have him "checked out." So, go figure.

I really do believe Medicare (and all such federal agencies) purposely confound and obfuscate to the point they can get away with anything. But I am going to give it one more try...
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Re: Anatomy of a Medicare Appeal

Postby gulfcoastpsp » Sat Aug 24, 2013 3:08 am

Hello Carla:

California and Washington DC hold hands daily, in my opinion. You might consider a different approach that allows you to think like they think so you win the negotiations, i.e., cost reductions. Use that as your basic premise. Sit back and listen...
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