Has anyone ever appealed a Medicare decision and won?

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Has anyone ever appealed a Medicare decision and won?

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My mom recently went into hospice care. She is also in a memory care facility. She had a fall recently and the facility sent her to the ER. They did not inform the hospice first. Hospice has already had me sign paperwork that they would still be the provider to be paid that day. So my mom may wind up needing to pay the hospital bill. I am waiting on the bill from the hospital and the denial of payment from Medicare now.
I am wondering about how to best appeal a denial to advocate for my mom.

Hospital Medicare Paying for Care

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I may be wrong, but I believe that the hospice agency you hired for your mom, should be the ones to contact the hospital, to let them know that all charges be covered by them. I know when my husband was under hospice care in our home and he had to go to the ER, the hospice nurse at the time said that he would call ahead to the ER to let them know my husband was coming, and that it was to billed to them. Well when I got there, no such call had been made I was told, but when I told them it was to covered under hospice, they apparently took my word for it,(I'm sure they looked into it as well) as we never received a bill for it. I would be calling mom's hospice agency and have them handle it. Good luck.

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Here's the way hospice handled it. They had me sign paperwork stating that they would be paid for her care on that day. I get to wait and see what Medicare will do. It looks like I will be appealing.

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In your situation any bill you get from the hospital should be forwarded to the hospice agency. Usually Medicare will also handle the situation for you because they are paying the Hospice Agency.

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Please note some of this discussion has gotten off track. The issue is who has liability for a person under an approved Medicare hospice situation, and who went to the hospital in an emergency situation without the hospice provider being given prior notice for its approval. I am sure Medicare will probably cover the emergency situation as long as it was not related to the hospice medical conditions.

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This is the facilities fault. They should have not sent Mom to the hospital without Hospice agreeing to it. IMO.

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Well, what was the reason she was sent to the hospital?

When mom was on home hospice, the reason they told us to call them first before we allowed her to be taken to the hospital was for hospice to give us advice on if it was "necessary" - and one of the things they specifically mentioned was going to the hospital for a fall. If she was sent because we or the EMT's suspected some sort of injury from the fall: ie - a broken bone, a concussion, etc. - then Medicare would pay for the visit, because any such injury wasn't one of the reasons she was under hospice care. But if she went to the hospital for severe edema, there was the possibility that mom would be responsible for the bill, because she was under hospice care for CHF, and edema is a symptom of that. In other words, Medicare isn't going to pay 2 different agencies/facilities to treat the same condition.

I can't imagine the facility your mom is in is not aware of these regulations in regards to hospital visits and hospice. I would try to find out what the reason for the trip to the hospital was and go from there. You might be worrying about something that will never come to pass.

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I believe many facilities send their elderly residents to the hospital as a matter of course after any significant fall even if no symptoms of injury are apparent. It's probably for a "CYA" reason to prevent liability issues.

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If it is medically necessary, they should pay Get the Dr to put that on the forms.

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Sadly, that doesn't always work. During the appeal process I submitted a letter from his Dr. specifically stating the necessity of the PT scan.....and also the fact that he assured my husband this would be covered through Medicare (he has never had this happen before). There are occasions when Medicare will reverse their decision, but not always. It's a slippery slope and one that sick, elderly people shouldn't have to face.Oftentimes, they have no one to advocate for them.

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When my Mother in law was w/ Lung Cancer two yrs. ago the hospital stay was DENIED by Medicare.
As her primary caregiver I was called on to appeal that decision. With the help of the hospital Social Worker I commenced doing so on a WEEKEND!

Truthfully, being a nurse & know ALL the medical jargon & understanding it was a HUGE plus. Also, I INSISTED on speaking with the PHYSICIAN handling her case.

Two days later the decision was reserved her hospital was extended & paid in full!

Tips:
1. Seek Social Worker’s help
2. Reach out to any health care worker ( doctor or nurse) in your family/ friends
3. Learn ALL medical jargon & understand it
4. Insist on speaking to Medicare Dr. handling the case.
5. Be Firm, Be Kind, Be Patient
6. Don’t Give up!

Best Wishes & Good Luck
for great outcome.

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Did you sign an ABN (advanced beneficiary notice)? They (hospice, hospital) would have had to tell you in advance that the service might not be covered by Medicare and along with that an estimated amount of how much it would cost. Sounds simple enough, but I had to fight for over a year with both the hospital and Medicare. It went to arbitration and from there, finally settled. Medicare DID NOT pay, but under contract, the hospital did not provide the ABN form and was in violation. This is the critical part....no ABN, no payment. The hospital had to eat the $10,000 plus charge. The ABN applies to all hospitals and providers that accepts Medicare. It took me a lot of time researching this.....and it seems to be a well kept secret. You have to know what it is to find it.......and then appeal the denial from Medicare (which is another whole process). It's sad to have to jump through all these hoops to get direct answers.....I think it's because they expect you to pay, even at the expense of their own mistakes. Good luck to you. I'd love to know how this works out. Just a reminder.....hold your ground and don't let them intimidate you.

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The ABN is supposed to be provided when a provider believes the service will not be covered by Medicare.

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I appealed a denial of ambulance service and provided logical reasoning why it should be paid. I won.

Was in hospital for compression fractures of spine and hospital arranged transport because she could not sit up long enough to move to rehab. That bill approved. Rehab ignored signs of a problem (critically low sodium) even w/me telling them to check levels due to symptoms patient complained of. They arranged transport back to hospital when test came back to move her STAT to hospital. Medicare denied the charge because facility failed to tell ems of the critical level sodium test. Hospital treated her several days and arranged transport to another rehab. Medicare paid that one. Based on being paid before sodium problem, after sodium problem and there had been no change in her abiity to sit up for a transport, I used that info to appeal. The judge called me on day of hearing and said common sense played a roll and reversed the decision.

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The only you did not mention is that you won after probably reaching the third level of appeal which is reviewed and determined by an Administrative Judge. [There are three more levels after this one.] It takes about 90+ days to reach this third level. Many people give up before they reach it. Also, the third level provides for either a hearing or based on the existing record review process.

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Some years ago a friend was involved in something similar and every attempt met with failure. She called me for help and when nothing worked, we threatened to go to the media. Well, I did just that - I went to the television station. As a result, the story and different segments of it were aired on television for five days. She won in the end. No facility likes to be put into the public media - try it and if need be do it - letters to editor, asking them to do a news story, etc. it often works.

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Where do you go when you first need a person to write . When you want the lawyers and loop holes addressed by officials that have already taken advantage and want to prove the sad loop holes in the system. There are no agency's in state, but there are laws.

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You are jumping the gun! In regards to your last comment. Besides you cannot do anything anyway until Medicare produces a Medicare Summary Notice. (Period)

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It’s possible that this is a tug-of-war between the provider and Medicare.

if you are ultimately denied, talk to the provider’s billing office. This might be something that providers expect Medicare may cover in the future, and through repeated billings, they may be hoping to create a precedent.

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Medicare does not play a tug of war. They will accept a correction by a provider, but never an argument.

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Imho, although it may never get to the level of needing an elder law attorney, you may want to retain one.

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Your suggestion is a good, but an expensive one. Therefore, one needs to ask oneself, is it really worth it?

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Ricky6 is right-on. Just as with many governmental agencies there is usually a long appeals process. Almost always, the first appeal is denied.( Try to file for SSDI) There is a slightly less chance that the 2nd appeal will be denied. The 3rd usually hits the sweet spot.

This is the same with many insurance companies, the first 2 are only looked at either by a computer or some file clerk that does nothing but look at the coding and most of the time deny, deny, DENY!!! There are a few codes that hit the spot and are not denied however the third appeal is reviewed by a Dr or a team of Drs who make and honest review of the case.

Good luck with Hospice. As previously stated If the ER visit was for the same diagnosis as the Hospice admittance, then it will most likely be denied, If it is connected to the Hospice diagnosis, it will probably be denied. ie. Hospice is based on CHF. Swollen legs cause cellulitis will not be covered because leg swelling is caused by CHF. However a cut on the leg (without swelling) get infected and results in cellulitis probably will be covered.

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In Medicare’s case, the First Level of appeal goes to the same Medicare Administration Office as the original claim. It’s just sent to a different office within the same Medicare Administration Office. The Second Level of appeal goes to (outside) third party Administration Office for Medicare. The Third Level of appeal goes to an Administrative Judge for Medicare.

if you are going to start an appeal get a copy of all the medical and hospital records together including the ambulance log.

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I suggest you temporarily get her off hospice if you don’t want her to pay the bill. It will be HUGE!!! Don’t wait till you get it in the mail. Hugs 🤗

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They cannot rewrite their coverage retroactively.

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Find an Estate or Medicaid lawyer they have all the loop holes, I have witnessed what they can do for family members who do not care for Mom. If your in NYS Nassau/Suffolk Law is supposed to be able to help at no cost to lower income Elderly.

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Personally, I think you maybe jumping the gun here. I would first see if Medicare does not pay the bill. Also, see how Moms suppliment handles it. As I said previously, the MC care facility is at fault. The staff should have been aware that Hospice needed to be notified before transporting Mom to a hospital.

So if anyone pays Moms bill, it should be the MC facility, again IMO. The error was theirs. Why should Mom be out the money.

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Has anyone ever appealed a Medicare decision and won?

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