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I did not set out to pick a fight with CMS and Weisberg. Weisberg showed nothing but contempt for my folks by her refusal to allow them the rights that had been established for Medicare managed care beneficiaries.
I do not know what her motive was. Perhaps a psychiatrist or her accountant might be able to provide some insight. I supplied Weisberg with an abundance of written and audio testimony, as well annotated documents, that clearly showed that the Advocate had repeatedly failed to abide by numerous CMS regulations.
Weisberg did not dispute the testimony and documents; she refused to acknowledge their existence! Advocate owned his network hospital, Lutheran General Hospital. Advocate was paid a monthly capitation per covered member to assume risk for all managed care services including professional and hospital costs.
My stepfather had surgery late in June at Advocate Lutheran General. I was informed by the hospital staff members that my stepfather would be evaluated to determine if he fit the criteria for acute PT.
Acute PT is intensive. I was later told that he had been evaluated and had been found not to be a candidate for acute PT. I was then advised that he would be sent to a skilled nursing facility where he would receive sub-acute PT.
In MarchI found out that my stepfather had never been evaluated for the acute PT. This individual did not realize that she was blowing the whistle on Advocate, her employer. She arranged for me to receive a copy of his evaluation form, which had not been included in his medical records that I had obtained after his surgery.
Advocate had lied to me in order to prevent me from filing a Fast Expedited Appeal. I think Advocate lied about that too. Remember, Advocate was paying for the therapy, albeit paying them self.
Acute PT is much more expensive than sub-acute. Regardless, if that were the case we should have been notified in writing, and then been offered an alternative source for acute PT. If none was offered, I could have then filed an Expedited Appeal. I provided Weisberg with a copy of the evaluation form, but she refused to acknowledge its existence.
Instead, she claimed that no service had been denied. She even went so far as to claim that there was no such thing as acute PT!
The following has been on the CMS website since at least You have the right to appeal any decision about your Medicare services. This is true whether you are in the Original Medicare Plan, a Medicare managed care plan, or a Medicare prescription drug plan. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.
If you are enrolled in the Original Medicare Plan, you can file an appeal if you think Medicare should have paid for, or did not pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case.
Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why your bill was not paid and what appeal steps you can take.
If you are in a Medicare managed care plan, you can file an appeal if your plan will not pay for, does not allow, or stops a service that you think should be covered or provided.
If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. The plan must answer you within 72 hours. The Medicare managed care plan must tell you in writing how to appeal.
After you file an appeal, the plan will review its decision. Then, if your plan does not decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. I did not need to prove that in order to prevent me from filing an appeal, Advocate had lied to me.
I have a recording of him telling me that CMS cannot do anything, nor could I file an Appeal, about a service that I thought that my stepfather should have received.
Obviously, this employee never looked at the CMS website.Aug 10, · Get ready for changes to your health care coverage; Physician Directory Find a doctor in your area; Pain Coach. Track your pain levels, triggers, and treatments.
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