MDA / Quest Vol 8 No 3 / Maneuvering Through Medicare

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QUEST Volume 8, Number 3, June 2001

MANEUVERING THROUGH MEDICARE

The system's got more pieces and more moves
than a chess game. Here are some guidelines to
help you reach checkmate.

by Jennie Borodko Stack

Tongue in cheek, Andy Laubert of Gardnerville, Nev., calls himself a "high-maintenance guy."

But Laubert's pricey requirements aren't the stuff of which glamour guys are made: Rather than striving for the perfect tan, he seeks the right power wheelchair; and instead of ultimate accessories for a Porsche, he orders supplies for his urinary catheter and two ventilators.

You, the insurance company, and the service provider

The sustenance for this high-maintenance lifestyle comes not from a trust fund or a movie deal, but from a combination of private long-term disability insurance, Social Security Disability Insurance and Medicare.

Laubert, who has limb-girdle muscular dystrophy, has received Medicare since 1990. His respiratory equipment alone costs $2,000 per month. He estimates his medical and personal assistance expenses at about $3,600 a month; then there are living costs, such as housing and food for his family of three.

Formerly employed by a publication for health care professionals and as executive director of an independent living center, Laubert is one of 5 million Americans with disabilities who receive Medicare. Like many recipients, he has mixed feelings about the program.

"On one hand it's coverage, which is great. No one in their right mind would insure me [privately]," says Laubert.

Still, he chafes under some of the system's inconsistencies, such as its denial of his claim for a breathing apparatus that supplements other respiratory equipment. Called a pneumobelt, it helps Laubert exhale by compensating for weakened respiratory muscles. Compounding his frustration, he's learned that Medicare does cover the same type of device for a friend on the East Coast.

"Medicare has refused to pay the vendor for that particular item," Laubert says. "Without it, I would need a tracheostomy, which they will pay for, which is kind of silly because you're talking about a device that costs $500 and doesn't require nursing care to maintain it." Laubert has purchased the pneumobelt out of pocket and is asking Medicare to reimburse him.

Learn the Game

Critics of Medicare say such contradictions are all too common in a massive program administered at the federal level and carried out by local and regional insurance carriers.

MDA National Task Force on Public Awareness member Alexandria Peck Berger of Portsmouth, Va., a disability advocate and syndicated newspaper columnist, also receives Medicare. She has myasthenia gravis and polymyositis and uses a power wheelchair.

Berger likens the process of maneuvering through Medicare to a game with certain standard moves. You apply for coverage, the insurance company denies the claim. You find out why, and resubmit with new information. They approve the claim. You win this round.

Alexandria Peck Berger

At stake in the Medicare game is a lot more than paper money in "Monopoly" or a reputation as a chess master.

In this "game," your financial resources and vital health care requirements are part of the gamble. As in a never-ending chess match, a Medicare recipient can feel like a perpetual pawn caught between the comparative royalty of a powerful insurance company on one side and the vendor or service provider on the other.

While it's common to feel frustrated at a system that may seem to pit patients against those charged with caring for them, Laubert, Berger and others say Medicare beneficiaries can take charge of their own health care. Becoming one's own best advocate requires mastering several key moves, including:

awareness of benefits
attention to detail in the procedure of filing and appealing claims
communicating well with everyone on your health care team, from doctors and nurses to therapists, vendors and home health organizations.

Know Your Benefits

As basic as it sounds, forms must be filled out correctly to be accepted and get the right results. Berger advises claimants to remind physicians to place the correct diagnostic code in the proper place on the form.

WHAT IS MEDICARE?

Medicare is a highly complex, $212 billion-per-year program that accounts for 21 percent of the nation's $1 trillion annual expenditures in the health care system. Begun in 1965 as a health insurance program for senior citizens, Medicare expanded in 1972 to include adults younger than 65 with disabilities of more than two years' duration. To receive Medicare for disability, you must first be enrolled in the Social Security Disability Insurance program.

Medicare is governed by the U.S. Department of Health and Human Services through the Health Care Financing Administration. Private insurance carriers contracted with Medicare process claims and make payments to institutions (such as hospitals and nursing homes), equipment suppliers and health care providers (such as doctors and therapists).

Coverage often differs among carriers, and in some states many carriers offer coverage. Guidelines also change periodically, so it's important to read your Medicare manual each year and keep up with changes.

In general, Medicare requires that medical supplies and interventions must be "reasonable and necessary" in diagnosing or treating an illness or injury. A prescription and sometimes a letter of medical necessity from a doctor are required.

What Medicare Provides

Medicare coverage is divided into two parts, A and B. Part A is free of charge to former workers and their spouses who were employed more than 40 quarter-years in situations covered by Medicare. (Those with fewer quarter-years of employment pay $165 to $300 per month.) Covered are hospitalization and follow-up care, either in a skilled nursing facility or through hospice or home health care.

Medicare Part B is medical insurance that covers doctors' and outpatient services (including some nursing facilities and in-home health care costs). This coverage is optional, with a $50 monthly premium and a $100 per year deductible for most, although there's assistance for those who meet income guidelines. After the deductible, beneficiaries pay 20 percent for many services, and 50 percent for some (such as mental health care).

Lab services, such as blood tests, are free, as are home health care and approved items of durable medical equipment supplied by the home health agency. Part B coverage includes braces for the neck, back, arms or legs, along with wheelchairs and other medical equipment. Medical supplies, such as casts, splints, dressings and ostomy bags, are covered as well.

Most prescription drugs aren't currently covered under Medicare.

In addition, read the Medicare Handbook to learn what you're entitled to. "It's critical that they understand it's just like an insurance company and they're going to have to fight with them like they do an insurance company," says Berger.

After struggling through the system and finally obtaining what's needed, recipients may breathe a sigh of relief only to discover the battle's not over yet. Sometimes a large bill arrives from the provider (equipment vendor, doctor or therapist, for example) with charges for something you thought was covered. The bill may be valid, or it might reflect an oversight on the part of either the provider or the recipient.

Berger advises clients who receive unexpected bills to carefully examine the claims form. If the phrase "provider accepts assignment" appears, then the vendor has agreed to take Medicare's predesignated payment amount as payment in full. (For more information, see "Durable Medical Equipment,")

"When a patient gets a bill from a provider and Medicare has paid $5 of a $250 claim, if it says on that claim, 'provider accepts assignment,' they [beneficiaries] owe nothing," she says. In such cases, she advises that you send a copy of the form with the phrase "provider accepts assignment" to the provider along with the bill. If that doesn't resolve the situation, she says, it's often worthwhile to mention that you plan to follow up with the state insurance commission, which investigates claims of insurance fraud.

Deny Denial

Those who know the Medicare system well say that denials happen so frequently they're almost routine. For example, a missing or incorrect diagnostic code means instant rejection by a Medicare reviewer. If your claim is denied, Berger advises, first call the doctor's office and ask the staff to recheck the diagnostic code and resubmit the claim with proper codes.

Laubert agrees. "Never accept a denial. If it's something that is necessary, you have to fight for that.

"If I've been denied, I will research a little deeper to see exactly what criteria they are using. I have found several times in their own regulations subsections that address specifically what I needed that they didn't catch. They may have been looking at the main part of the regulation but didn't bother to look at some of the provisions."

If the claim is denied even with proper codes, then you have to appeal, which can be a lengthy process requiring persistence and extensive documentation. The majority of Medicare denials are never challenged, but most challenges succeed, according to Suzanne Levin, director of client services at the Medicare Rights Center in New York. As with any procedural question, understanding the terminology and knowing where to look for answers both go a long way toward success.

Generally, Medicare's universal standard for covering an expense is that the service or item is "reasonable and medically necessary."

Once a Medicare Part A claim is filed, an initial determination is made by the fiscal intermediary (insurance company for an institution such as a hospital or nursing home) and sent to all parties involved. If a decision is unfavorable, you or your doctor or other provider may request a review in writing within six months of receiving the decision. If the review also is unfavorable, you can ask for another examination by a provider's staff member not involved in the first decision.

In Part B, consumers can appeal a denied review to the insurance company for claims under $100.

In both Parts A and B, claims for at least $500 can be appealed to an administrative law judge, and those over $1,000 can go to federal court. (See "What Is Medicare?" for an explanation of Parts A and B.)

Communicate With Your Team

The best preparation for the purchase of a major piece of equipment or an extensive therapy program is communication with your health care team, from doctors to therapists to vendors. Experts recommend knowing for yourself exactly what's needed, then approaching the doctor, who must prescribe it.

"I'll tell you what, my therapist and doctors love it because when I come in I already know what I need and what I want. It makes their job a lot easier," says Laubert.

Since it may be unrealistic to expect busy doctors to know exactly which make, model and style of equipment will best suit your needs, Berger recommends bringing along a brochure or other product information as a point of reference when you see the doctor. You can get advice on equipment by talking with several therapists (physical, occupational, speech or respiratory).

Another valuable ally is a durable medical equipment vendor, especially one who accepts Medicare assignment (see "Durable Medical Equipment"). Even if they don't take assignment, vendors are usually quite knowledgeable about the equipment they sell, and may be willing to work with recipients on prices or payment arrangements.

Hospital medical social workers offer referrals to a wide range of service and equipment providers, tailored to the needs of the individual.

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