Health Care Grief

Who What Where When and How-I hope someday that Advocate Health Care will be forced to answer Why

2011-07-13T18:00:00.003-05:00

This is not a traditional blog in that it is not a journal. I created it to store annotated documents that illustrate how Advocate Health Care, of Oak Brook, IL., circumvented several Centers for Medicare and Medicaid Services regulations, with the blessing of CMS. These regulations were established to protect Medicare + Choice (Medicare Advantage) customers from being wrongly denied essential health care.

The result was that several Advocate Health Care beneficiaries, endured a lot of harm.

Unfortunately, not a lot of people give a damn...even though anybody who has a Medicare or Medicare Advantage policy, should be very concerned, because the same thing can happen to them.

Advocate CEO, James Skogsbergh, rewarded by Mayor Rahm Emanuel

2011-07-13T16:54:00.000-05:00

As I have written before, nobody has ever been willing to make Skogsbergh accountable for the harm that Advocate caused to my folks. I understand that probably nobody reads this, but we did not have the money, and thus the power, to pay for justice...so this is the best that I can do. I want to keep the memory of what happened to my folks alive. I do not intend it to be an extended rant, and that is why I have documented everything so carefully. Perhaps, someday, somebody important will be harmed by Advocate, and then the...uh...wrongdoers...at Advocate, might be made accountable.

Jim Duffett's still taking blood money from Advocate Health Care, via his Campaign for Better Health Care

2011-06-28T20:34:00.006-05:00

It is absolutely sickening that Jim Duffett, the man behind the Campaign for Better Health Care, is taking money from Advocate Health Care. Advocate officials have never been made accountable for the deception that they perpetrated in the process of denying the beneficiaries specific medical procedures. The denial of the procedures caused the beneficiaries to suffer, and caused more medical problems for the beneficiaries. It is most likely that the wrongdoing, eventually led to the death of one of the beneficiaries.

Prior to my finding out that Duffett was accepting money from Advocate, I had wondered why his staff was relatively complacent when I presented them with the documentation of Advocate's wrongdoing. I was not seeking assistance from them, I merely wanted to illustrate how health insurance is a moot point, if the proper health care is not delivered, and how Advocate circumvented the CMS's regulations.

Several times I had asked to speak with Duffett, but he was always unavailable.

Now, I know why.

2010-10-19T19:51:00.004-05:00

It has been six years, since I was able to prove how Advocate Health Care denied several of their beneficiaries, the health care that was recommended by the beneficiaries' specialists. As I have stated elsewhere, nobody thought that it was a big deal. James Skosburgh is still head of the health care provider that caused a lot of physical and emotional pain for the beneficiaries.

It is too bad that Skosburgh is so lacking of integrity, (as are other Advocate officers), that he refused to meet with me to discuss the documents that I acquired.

My mother and my stepfather are now deceased. My stepfather passed away in January 2010. Advocate Health Care is currently running a television ad campaign.

Like Hogan's Sgt. Schultz, Senator Dick Durbin's Policy Director, Tom Falleti, wants to know nothing.

2008-10-08T17:08:00.020-05:00

After over four years, I finally received a response from Senator Dick Durbin's office via a letter from Durbin's Policy Director, Tom Faletti. As has been the case with virtually all of the other political and government employees that I have had correspondence with over the past five years, Faletti's letter was void of fact.

At one point, even though he acknowledges that I was not asking Durbin's office to make a judgment about a health care quality issue, Faletti still suggests that I should solicit the opinion of doctors. I advised Faletti in my response, that a doctor's opinion is not necessary in determining if any Centers for Medicare and Medicare Services regulations have been violated.

I spoke with Faletti before faxing him my rebuttal letter. Faletti was very adversarial. Until a new president is sworn in, CMS is George Bush's agency. I cannot understand why the Policy Director of the (Democratic) Majority Whip of the US Senate, would not want to know about Bush's CMS' wrongdoing. However, Faletti defended CMS. When I offered him the documents that proved the wrongdoing, he wanted nothing to do with them. (I faxed some to him anyway.) He was adamant about not wanting to make a judgement about if there had been wrongdoing. If ignorance is bliss, then I wonder why Faletti was so cranky.

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letter from Faletti (page one)

letter from Faletti (page two)

rebuttal to Faletti (page one)

rebuttal to Faletti (page two)

rebuttal to Faletti (page three)

Advocate executives donate to American Hospital Association PAC which in turn donates to almost everybody in Washington, DC.

2008-09-22T13:48:00.017-05:00

According to campaignmoney.org Advocate Health Care executives, including Dan Schneider, Lee B. Sacks, MD, and James Skosburgh, have donated money to the American Hospital Association. That should be no surprise because the AHA goal is for the welfare of the hospitals. However, according to several AHA employees, they are not advocates for the welfare of the patients.

George Burkstrom, of the AHA Membership Department, stated that he was not inclined to learn about wrongdoing committed by AHA members. Even though I never stated to him otherwise, he repeatedly told me that AHA would not intercede in such matters. This is one of the ways people at these institutions attempt to derail conversations. It is obvious that they do not have judicial jurisdiction over their members, but they make that an issue in order to justify their overlooking any wrongdoing committed by its members.

I reminded Burkstrom that our conversation was on the record, and then I asked him if AHA's only concern is that the members pay their dues and donate to its PAC, but he refused to answer and then he hung up on me. Of course, I knew before speaking with anybody at AHA, what its position is, but I had to give them an opportunity to provide it in their own words before writing about it. Before he hung up, Burkstrom told me that I should speak with somebody in AHA's media relations department. I left a message with that office, but I did not receive a callback.

The AHA PAC contributes money to hordes of Members of the US Senate and the US House, in fact they cover themselves evenly. All but one of the current members of the US Senate Finance Committee have received money from AHA PAC. The AHA has also contributed money to the campaigns of alleged health care advocates Senators Barack Obama, Richard Durbin, and Edward Kennedy.

Congressional workers need to get a clue.

2008-08-25T19:02:00.001-05:00

It was a sweep. I was blown off by numerous staff members in the offices of all my Congressional representatives. I never spoke with any of the representatives themselves, but they are responsible for the performance of their respective staffs.

I would like to be able to feed this into the collective minds of the said Congressional workers. They could use it for a role reversal excercise, but on second thought, I do not think that their arrogance and ignorance would allow them to be able to empathize.

Health and Human Services Office of Inspector General gave Bette Weisberg and her crew a pass.

2008-07-31T15:44:00.001-05:00

In August 2004, I filed a written complaint against Centers for Medicare and Medicaid Services Region 5 Medicare managed care manager, Bette Weisberg, and her crew. In the complaint I stated that CMS had allowed Advocate to violate numerous Medicare managed care regulations.

A month later, I received a letter from HHS/OIG that acknowledged my letter, but it stated that my complaint was against Advocate. I called the sender, Jaishiri Mehta, and advised her of the wrongdoing that CMS had committed. I told her that I would send her the corroborating documents, and that I wanted to discuss them with her. She agreed discussing them with me.

Mehta sent me a September 29, 2004 email message in which she acknowledged receiving the documents. In this email she states that she will contact me after she has a chance to look at them, ostensibly to discuss them with me. That was the last that I heard from her until she sent me another email (both emails are available via the link) in response to my subsequent phone calls. In that email she contends that she cannot speak with me.

In December 2004, I received a letter from OIG "special investigator" Scott Vantrease in Chicago. The letter stated that their investigation had concluded, and that CMS personnel had done nothing wrong. I called Vantrease, and told him that there could not have been much of an investigation because I was never questioned, nor did I have an opportunity to discuss the documents with anybody.

Vantrease told me that he had more important things to do than deal with my complaint. However, he said that if I called him after the holiday, he might be able to put me in contact with somebody who might be able to resolve the matter.

On December 30, 2004, there was a message on my machine from a "special agent from Homeland Security, regarding a Health and Human Services complaint". The next day, nobody answered the phone at Homeland Security. I was not able to get a hold of the "special agent" until January 10, 2005. During that phone call, the "special agent" threatened me with "prosecution" if I did not "cease and desist" from communicating with HHS/CMS. I asked him what I had done to warrant such a threat, but he said that it was not his job to tell me. I asked him what I would be prosecuted for, and he said that he would "find something". Then he hung up on me.

It turned out that he was an employee of Federal Protective Services, which is under Homeland Security. After that one call, I never heard any more from him.

Somebody at HHS/CMS had used the Federal police force to try and scare me off from attempting to obtain the rights of my parents. I didn't get worried about the call until it became apparent that nobody that I told about it thought that it was a big deal. That is really scary.

Advocate Health Care just kept on lying and lying and lying.

2008-07-19T17:46:00.000-05:00

When it comes to overseeing the health care needs of others, it is difficult to be vigilant without being a pain in the ass. For that, I am guilty.

Prior to 2003, I had spent years fighting to get the appropriate health care for my folks. The fight included using the Medicare managed care Appeals process, which I successfully navigated in the late 90s. After that, obtaining the proper health care for my folks became somewhat easier. That was until 2003.

Advocate Health Care personnel did so many heinous things that it is difficult to say which was the worst. However, the following would have to be among the worst, especially because it was so...diabolical.

In 2003, my mother, stepfather, and I all had serious health issues. Mine included having a heart attack and needing quadruple heart bypass surgery. However, I did not have insurance, so it took a few months before I found somebody who would do the surgery. The tentative date coincided with the sub-acute physical therapy (PT) that my stepfather had been receiving after he had surgery in June 2003.

I had been in constant contact with the Advocate attending physician and nurse who were supposed to be coordinating his PT at Chicago's Warren-Barr Pavilion, a skilled nursing facility. He had been admitted there in early July 2003, and was scheduled to have the PT for at least eight weeks.

My stepfather was supposed to receive a treatment with a nebulizer (to aid in breathing) twice a day or as needed during his stay at Warren-Barr. He was not given this treatment until after he had been there for three weeks, and then he only received it a couple of times.

His prescribed diet initially consisted of pureed food (mush). Since he had had surgery on his neck, there was concern about him swallowing properly. The diet was supposed to be switched to that of a normal diet within a few days after arriving at Warren-Barr, but most of his meals remained pureed, despite repeated reminders to the kitchen. He didn't have much of an appetite for slop, so I started bringing food in from the outside.

My stepfather received sub-acute physical therapy about five days a week, but not at any specific time. There was not any specific length of time for each session either. I was not able to be with him everyday, but for a while, another family member stayed with him, and she said that there were some days when he did not have his scheduled PT. He never regained his strength or weight while at Warren-Barr.

I spoke about this with Nancy Meyers, the attending Advocate nurse. In early August 2003, she told me that my stepfather was not doing well in therapy, and that he would probably have that service suspended shortly. My bypass surgery had already been postponed several times, and I told Myers that it was important for me to know when my stepfather would have to leave Warren-Barr so that I could make plans for his care while I was recuperating. If my stepfather had been able to assist himself, there would not have been a problem in having him come home. However, Myers had told me that he might never walk again, and that meant that he would need somebody to care for him while I recuperated. (For example, after my surgery, I could not do any heavy lifting so that my chest could heal.)

My surgery was finally scheduled for August 20, 2003. On August 18, 2003, I told Myers that it was set for the 20th, and we also spoke about about my stepfather's progress. I asked her what would be the earliest date that he would have his PT terminated. She told me August 29, 2003 (eight weeks from when it started).

On August 19, my surgery was postponed again. Advocate had no way of knowing this. On the morning of the 20th, I received a call from a friend whose number I had given out for emergency purposes. Somebody from Warren-Barr had called him and said that my stepfather's PT was going to be terminated on August 22, 2003. They wanted to know where my stepfather should be transferred. After hearing, this, I immediately called Dr. Rajan Raj, his surgeon, and Raj told me that the sub-acute PT that my stepfather had received had not been adequate. I asked him to put his opinion in a letter, however, it took him about four months before he wrote one. (I had only agreed to the sub-acute PT because Advocate personnel had deceived me by telling me that he had not fit the medical criteria for acute PT.)

The next thing I did was to call the insurance company's Expedited Appeal phone line, and I appealed the pending termination of my stepfather's PT. I stated that since he could not even walk or stand up under his own power, that terminating his PT would adversely affect his health. I asked for an extension of the Appeals process to fourteen days, in order to give time for me to obtain the surgeon's input. (Raj should have filed the Expedited Appeal himself, but he later indicated to me that he had no stomach for hassling with the Expedited Appeals process. If anything, he was guilty of being unethical.)

No action regarding the termination of my stepfather's PT should have been taken until a decision was made in response to the Expedited Appeal that I had filed. Since there is no guarantee that we would have had a ruling in our favor, we risked having to pay out of pocket for any additional time that he stayed at Warren-Barr while he was not being covered by his insurance. However, he was being shorted one week anyway, so the risk should have been limited to only a week.

At the same time, the Advocate attending nurse, Myers, told me in a telephone conversation, that the decision to terminate my stepfather's PT had been made on August 19, 2003, during the scheduled weekly meeting to review his case. The conversation was bizarre because she denied telling me that the earliest that he would have his services terminated would be on August 29. Furthermore, I asked her for copies of the meeting notes, and she told me that there weren't any. She also told me that she had not heard anything about my filing an Expedited Appeal.

Things were not going well at all, and I did not have the luxury of being able to sit back and analyze the situation. I arranged for him to be placed in another nursing home. He was transferred there on August 22, 2003.

The next thing that I received regarding the Appeal was a September 8, 2003 letter from the HMO stating that the Expedited Appeal had been given to "Quality Management". My subsequent phone calls to the Grievance and Appeals Department went unanswered. My Expedited Appeal had been misclassified as a Grievance. The only thing required of the insurance company in response to a Grievance, was to do an internal investigation. It does not serve the same purpose as an Expedited Appeal.

It turned out that Advocate had informed the insurance company that I was simply unhappy with the PT that my stepfather had received, and that I had been in denial about his negative prognosis. This deception is why the insurance company classified my Appeal as a Grievance. Grievances deal with quality of care issues.

The sleazy charlatans of Advocate really out did themselves this time. First, they lied to me about when my stepfather would have his PT terminated. Then they waited until the day that they thought that I would be having quadruple bypass surgery to make the announcement that (two days after my planned surgery) his PT would be terminated.

The cancellation of my surgery, foiled their plan to avoid me appealing the premature (by a week) termination. However, they still managed to dodge the Expedited Appeal by lying to the insurance company about my motive.

If this is hard to follow, it is probably because one might have a hard time comprehending that a faith based non-profit organization such as Advocate Health Care, the largest in Illinois, and one of the biggest in the country, could be so inhumanely ruthless.

But they are!

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Note:

As I have written in a previous post, Advocate has refused to provide us in writing with the criteria and rationale, specific to my stepfather's case, that was used in deciding that his sub-acute PT be terminated. They are required to do so by Medicare regulations. Instead, a year or so later, Dan Schmidt, then the President of Advocate, had one of his assistants send me some generic CMS classifications about skilled nursing facilities. Former CMS manager, Bette Weisberg, allowed them to get away with violating the CMS regulation regarding disclosure.

Faith based not for profit Advocate Health Care...ya wanna buy a bridge?

2008-07-17T15:43:00.000-05:00

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Note:

Several years ago, I spoke with Rev. Kirsten Peachey, the Director of Advocate Community Ministry. I had thought that since Advocate claims to be faith based, that somebody like Peachey might offer some assistance in resolving the matter of getting Advocate to do what they are required to do by Medicare managed care law. Peachey told me that she would be speak with Wagenknecht, and get back to me. I did not hear back, and I called several more times over a long period, and left messages with both of them. As of July 17, 2008, neither of them have responded.

Today's vocabulary lesson features the term "blood money". It means compensation paid to the family of somebody who has been killed.

2008-07-16T17:03:00.002-05:00

Can you imagine People for the Ethical Treatment of Animals accepting sponsorship money from the American Meat Institute? I can't. However, I never imagined that the Campaign for Better Health Care would accept sponsorship money from Advocate Health Care either.

Funny, I do not see Advocate's name on the list of Health Care Justice Endorsers.

I wonder if Jim Duffet, the founder of CBHC, has installed red lights outside of his offices.

Former CMS employee Bette Weisberg allowed Advocate's involuntary disenrollment of the beneficiaries.

2008-07-14T22:09:00.004-05:00

In March 2004, I received a letter from my folks' HMO stating that their Primary Care Physician, Michelle Seo, had requested that my folks be kicked out of the Advocate Health Care provider network. The letter referred to a breakdown in the doctor-patient relationship. They were given a choice of three other network regions, the closest one being an hour or so away.

I called Seo's office, and spoke with one of the nurses. She told me that the decision had nothing to do with Seo, but was in response to my having filed a complaint with the Illinois Department of Professional Regulations against two Advocate doctors, David Kushner and Abkar Khan.

Kushner had been my mother's hospitalist (attending physician) at Advocate Lutheran General Hospital when she was admitted there in April 2003. He was one of the doctors who ignored her medical history, and inspite of my protests, he took her off of a medication.

My mother had not been eating because she was in a great deal of back pain. Kushner told me that he had taken her off the medication because it causes anorexia. I explained to him that it was the pain that was causing her "anorexia", but he ignored me. He also refused to consult with the specialist who had prescribed the medication.

Prior to her hospitalization for the back pain, the biggest problem that we had had with my mother was that she would try to walk around without her walker. After two days in Lutheran General, she was rendered incontinent, and was never able to walk again. She eventually had to be placed in a nursing home.

Khan was the attending physician at Governor's Park in Barrington, IL. That was the nursing home she was sent to ostensibly for sub-acute physical therapy. She had been discharged from the hospital after two days, and had been diagnosed as having a compression fracture in her back. I never was given any proof of this, and had I not been busy having a heart attack, I would have appealed her being discharged so soon.

While at Governor's Park, she was given so much pain medication, that she was somnolent. Consequently, she was not enthusiastic about doing any physical therapy. She did have a history of mild multi-infarct dementia, which was exacerbated by the drugs. I pleaded with Khan to intervene, but without any luck. There were many more problems at Governor's Park, but since I was not as famiiar at that time with the Appeals process, I made some errors in reporting the problems.

Considering that CMS did not enforce the regulations about Appeals, I do not know if I would have had any luck if I did make my complaints about Governor's Park properly.

She was first discharged from Governor's Park in May 2003, at which time she was so doped up that she could not sit up in the car. I brought her from the back of the place to the front, and requested that she be checked back in. They did so as a "favor", but only for several days, until I could find a nursing home to place her in.

It is important to mention that the staff at Governor's Park were insistent that she had Alzheimer's. They ignored me when I told them that the drugs were causing her to be so confused. On top of that, I later found out that she had had a bladder infection while at Governor's Park, and that that could have contributed to her confusion too.

I found a nursing home to place her in, because there was no way that I could have attended to her at home anymore. She survived two years there, and I will touch on that in another post. However, after about a month or so, she was finally backed off on the abundance of meds that she had been prescribed in Governor's Park, and literally within a day or so her cognitive ability bounced back. Unfortunately, she remained incontinent and unable to walk.

CMS had to approve my folks being disenrolled from Advocate, and Weisberg once again gave Advocate her blessing. Her account of why they were disenrolled was in line with Advocate's official (fact free) reason, and the language that she used to describe the reason sounds like collusion. In a August 2004 letter to me, Weisberg wrote that my "behavior" had caused my folks to be kicked out of the network. She just could not resist getting in a dig at me.

More CMS BS from Weisberg

Former CMS staff member Bette Weisberg enabled Advocate to dodge explaining health care decisions.

2008-07-13T14:47:00.002-05:00

Another regulation that former CMS Medicare managed care manager, Bette Weisberg, enabled Advocate Health Care to violate, is one that requires that the beneficiary be advised in writing as to the criteria and rationale that was used in making any organization determination about their health care.

The following is from Chapter 13 of the Medicare Managed Care Manual.

The manual provides an example of unacceptable language and the acceptable language that is to be used. The criteria and rationale should be restricted to the progress of the patient, not generic and rambling CMS definitions. For example, a correct written response might look like the following.

• The case file indicated that while [Stepfather] was making progress in his therapy programs, his condition had stabilized and further daily skilled services were no longer indicated. The physical therapy notes indicate that he reached his maximum potential in therapy. He had progressed to minimum assistance for bed mobility, moderate assistance with transfers, and was ambulating to 100 feet with a walker. The speech therapist noted that his speech was much improved by 6/12/2001, and that his private caregiver had been instructed on safe swallowing procedures and will continue with feeding responsibilities.

This level of information has never been provided to us by Advocate, and it had made countless decisions over the years about my stepfather and mother's health care. In fact, the only written notification we were ever given, was always done with "unacceptable" language.

I informed Lee B. Sacks and Dan Schmidt at Advocate about this. (Sacks is the Chief Medical Officer, Schmidt the President of Advocate Health Care.) In response, Schmidt had an assistant send me some generic crap about skilled nursing facilities. That shows the amount of contempt that Advocate holds toward its beneficiaries. Sacks weighed in with the same inane comments, and I think that he should lose his license to practice medicine. Finally, I was summarily dismissed by former Advocate Assistant General Counsel, Thomas Babbo.

Of course, this was all totally acceptable to Weisberg.

What this all means is that Advocate never had to explain the medical criteria and rationale, particular to my folks, that was used in making decisions about their health care. I think that that is a good thing for Advocate, since those decisions seemed to be more concerned with its bottom line than the well-being of my folks.

I liken Advocate Health Care to an organized crime organization.

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Note: I have edited out the name of the HMO because I have determined that Advocate deceived it, as much as Advocate deceived us.

The following are links to the first letter that I wrote to Advocate's Chief Medical Officer, Lee B. Sacks, MD, in 2004.

The following is a link to a copy of the letter that I faxed to Dan Schmidt as a follow up to my phone call with him.
Letter to Schmidt

The following is a link to a copy of the letter that I faxed to Assistant General Counsel Thomas Babbo in response to his August 20, 2004 letter to me. It did not render a response.
Letter to Babbo.

Advocate's money vs. my folks' lives...no contest.

2008-07-12T22:29:00.000-05:00

Advocate Health Care has non-profit status. That's little consolation to my stepfather. However, it does mean that Advocate's IRS form 990 is available on the Internet at Guide Star.

The attachment shows how much some of Advocate's crew makes.

Lee B. Sacks, Advocate's Chief Medical Officer, was instrumental in seeing that Advocate successfully violated the CMS regulations.

Former CMS employee, Bette Weisberg, enabled Advocate to violate numerous CMS regulations.

2008-07-12T20:23:00.002-05:00

I am not sure where former CMS Medicare managed care manager Bette Weisberg slithered off to after she left CMS. I did not set out to pick a fight with CMS and Weisberg. I had foolishly thought that CMS would assist me in obtaining the Appeals rights that had been dodged by my folks’ Medicare managed care provider, Advocate Health Care.

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. Weisberg’s stamp of approval allowed Advocate to get away with violating numerous CMS regulations, thus expediting the harm done to my folks. 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!

My stepfather's Primary Care Physician and all of his specialists were employed by Advocate. Advocate owned his network hospital, Lutheran General Hospital. Advocate had a risk sharing agreement with my stepfather’s Medicare managed care HMO (insurance company). 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 2003 at Advocate Lutheran General. His surgeon had informed me that he wanted my stepfather to receive acute physical therapy at Lutheran General’s 6th floor rehabilitation unit after his surgery.

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. I did not file an Expedited (Fast) Appeal, because I had been told that acute PT would be too rigorous for him.

In March 2004, I found out that my stepfather had never been evaluated for the acute PT. Another Advocate employee advised me that he did not receive the acute PT because the HMO (insurance company) would not pay for it because the service was “out of network”. (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 will never know if the insurance company had advised Advocate that the 6th floor rehab center was not a part of my stepfather’s network. (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 brought this to the attention of former CMS Region V Medicare managed care manager, Bette Weisberg, and her crew. 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 2003.

Medicare Appeals and Grievances

Your Medicare Appeal Rights:

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.

Appeal Rights Under the Original Medicare Plan:

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.

Appeal Rights Under Medicare Managed Care Plans:

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. See your plan's membership materials or contact your plan for details about your Medicare appeal rights.

I did not need to prove that in order to prevent me from filing an appeal, Advocate had lied to me. However, another CMS employee contradicted the aforementioned paragraphs from the CMS site. 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. Furthermore, he could not get it through his thick head that my stepfather’s surgeon was the individual who requested the acute PT.

Unfortunately, nobody I have contacted is interested in making anybody at CMS accountable for Weisberg and her crew's illicit actions.

I can be AARP's - Divided We Fail friend on My Space, but I am not allowed to talk to its policy makers.

2008-06-26T13:18:00.000-05:00

Today, June 26, 2008, I spoke with Gerardo Cardenas of the AARP Illinois – Divided We Fail media relations office. I asked him if his employers had any mechanism in place by which individual members could provide input, preferably in person, with the principal people within the AARP - Divided We Fail network. (Cardenas formerly served as Illinois Governor Rod Blagojevich's Chicago Press Secretary and Hispanic Liaison.)

Initially he kept directing me toward the Divided We Fail web site, and the “Share Your Story” feature. I advised him that that was a nice way for AARP to get people to feel involved, but that I wanted to do something more than tell anecdotes. He also mentioned that AARP – Divided We Fail has both a My Space and a Facebook account. I told him that I was not calling to find a date.

He then said that there were numerous gatherings where individuals could provide input. After repeatedly asking him to give me some examples, he finally gave me two, however, the gatherings he referred to had not had anything to do with Divided We Fail other than Divided We Fail had been “invited to attend”.

Finally, he admitted that there is no way that an AARP - Divided We Fail member can meet “one on one” with an AARP - Divided We Fail employee (policy maker). I told him that a literal “one on one” meeting would be nice, but that I would also be interested in being able to speak with the policy makers via a group of other people, as long as the meeting was limited to AARP - Divided We Fail business. He told me that that was not possible, but refused to tell me why. Then he referred me back to the Divided We Fail web site and the “Share Your Story” feature, after which he then hung up on me.

Note-
I told Mr. Cardenas that I initially had been referred to Ms. Terri Worman, Associate Director, AARP Illinois, but that she had not responded to my voice mail messages or my email. I mentioned that I had searched her name via Google, and learned that her expertise is that of a community organizer for the GLBT community, especially for the senior citizens who are a part of that demographic. Cardenas interpreted my comment as being a personal attack on Worman. I explained to him that I was just repeating the information that praised Worman and that I had read on the Internet, but Cardenas insisted that it was a personal attack.

Next I called AARP's main number again and asked a very nice operator if there were any other offices that I could call to get my questions answered, since I was not having any luck with the Illinois office. She told me that she has been told to direct people only to their state offices, and that she did not have a number for a national office.

That means there are fifty state offices divided up amongst the US. I guess that "Divided We Fail" is an appropriate name for this organization.

According to AARP, "Divided We Fail (www.dividedwefail.org) is a national initiative led by AARP, Business Roundtable, Service Employees International Union and the National Federation of Independent Business, to give a voice to millions of Americans who are tired of letting Washington gridlock stand in the way of affordable, quality health care and long-term financial security. Common sense solutions are needed, and everyone – individuals, businesses and government – has a role and a responsibility in ensuring health and financial security for all."

AARP is the only organization that I am entitled to join.

Another reelection campaign and another letter requesting Melissa Bean to be accountable for her House staff.

2008-06-25T22:38:00.004-05:00

This letter was faxed to Melissa Beans House office in Washington DC on June 25, 2008. I will note here whether or not it renders a response.

Update: What a surprise! As of October 1, 2008, I have not received a response from Melissa Bean to the aforementioned letter. However, I am certain that Melissa has been busy attending to her sore feet, the result of all of her parading around over the summer.

Email to Terri Worman, AARP Illinois Executive, regarding Divided We Fail

2008-06-25T20:49:00.001-05:00

On June 20, 2008, I was informed by numerous AARP employees via my phone inquiries, that Ms. Terri Worman is the AARP employee who will answer any questions that I have about the AARP program, Divided We Fail.

I left a voice mail message for Ms. Worman last Friday, June 20. Her outgoing message stated that she was out of her office, but that she would be returning to her office and returning calls on Monday, June 23.

I mailed her the email posted above on Tuesday, June 24.

Update:

As of June 28, I have not heard from her.

Health care advocate/mercenaries get press in the Chicago Tribune

2008-06-25T12:58:00.000-05:00

An article titled “Health-care advocates do the job if you have the money, Experts will guide you through tricky health-care maze” appeared on the front page of the June 22, 2008 edition of the Chicago Tribune. It was written by Tribune reporter, Judith Graham.

I once spoke by phone with Ms. Graham, in an attempt to tell her about my experience serving as a health care advocate on behalf of my folks.

However, Graham was not interested. I had explained to Graham that I was not seeking publicity, but that I wanted simply to convey my experience. The aforementioned article is a good example of why I thought that a reporter would be interested in learning about the wrongdoing that I have encountered.

There is not really a “health-care maze”. If I was able to figure it out, then any reasonably intelligent person should be able to figure out how to handle any health care issue. Doing so is time consuming, but not that complicated.

The problems that I ran into were not due to a “maze”, but rather because my folks' Medicare managed care provider used deceit to dodge the Medicare managed care regulations. The regulations are supposed to be enforced by the Centers for Medicare and Medicaid Services; they have been established to prevent the Medicare managed care policyholders and providers from placing their bottom lines above the well-being of the beneficiaries. In our case, CMS has given the provider its approval for dodging the regulations.

According to Graham, “The field is known as "health-care advocacy”, and services typically assist with everything from resolving insurance disputes to researching treatment options to connecting people with medical resources.” This is all done for a fee, ranging anywhere from “$395 a year” at one company, to “$200 an hour” at another.

One of the companies mentioned is “an upscale solution, serving as the health-care equivalent of an exclusive, high-end private banker for more than 3,600 clients.” Graham writes that, “Today, at least 20 families on Forbes' list of the richest Americans are clients, paying from $10,000 to upward of $50,000 a year for a PinnacleCare membership.”

Graham provides an example of a man who purchased the services of PinnacleCare for his wife and three adult children. She writes, "Late last year it cost $41,000 a year for a VIP package for himself and his wife, ensuring that a top-notch physician would oversee all their medical needs; $30,000 a year for a package focused on healthy living for his three adult children and their families; and $21,000 for a one-time fee to compile comprehensive electronic medical records for everyone.

In all, that's $92,000 paid on health-care advice by this 66-year-old entrepreneur before a dollar was spent on medical services actually delivered."

These companies advocate because they make money doing it. I advocate because it is my folks that need the help. I do not know what PinnacleCare does that I have not done, but I sure would like to find out what they do for $50,000 a year.

I wonder if my folks had been wealthy, if that would have made a difference in how the provider chose to abide by, and how CMS chose to enforce, the CMS regulations.

If Graham had bothered to take a little bit of time to learn about my experience as a health care advocate, she might have wondered the same thing.
-----
Note:On June 22, I sent an email to Ms. Graham, in which I reminded her that I had tried to tell her about some of my experiences, but that she had not been interested. She wrote me back almost immediately, and stated that she has talked with a lot of people, and that she was sorry if she had offended me.

Medicare Rights Center anything but

2008-06-23T02:12:00.000-05:00

From the Medicare Rights Center website as of June 18, 2008:

“History

The Medicare Rights Center National HMO Appeals Hotline, in operation since September 1997, provides direct assistance to older and disabled people who have had necessary care denied, reduced or terminated by their Medicare HMO. From September 1999 through August 2000, MRC's HMO Appeals Hotline handled 709 cases, secured much needed care for our clients, and saved them over $360,930 in out-of-pocket costs.

The Appeals Process

Our counselors guide callers through the HMO appeals process and, when necessary, intervene on their behalf with Medicare HMOs. After getting basic information about the problem, MRC staff either provide clients with information about how they can handle their own appeal or intervene directly on behalf of clients with their HMOs. In the typical case in which MRC intervenes on the client's behalf, hotline staff telephone the HMO to gather information and to advocate informally for our client.

When informal advocacy fails, MRC may write a letter to the HMO asking it to reconsider its denial. These letters contain facts, regulations and supporting documents pertaining to the case. MRC routinely sends a copy of this letter to the appropriate Health Care Financing Administration regional office, since we believe it is important to keep HCFA apprised of individual problems in a particular HMO as well as systemic problems that we observe when a large number of our callers run into the same difficulty.”

(The Health Care Financing Administration, or HCFA, became the Centers for Medicare and Medicaid Services in 2001)

One would think that an organization claiming to “institute more consumer protections for people enrolled in private Medicare plans”, would welcome well documented testimony about the wrongdoing perpetrated by a major private Medicare plan, with the blessing of the Centers for Medicare and Medicaid Services.

Furthermore, one would think that such an organization would post on its website, the criteria required in order to receive its assistance.

Neither is the case.

For at least a decade, my folks’ Medicare managed care HMO has referred its beneficiaries to the Medicare Rights Center for assistance in filing appeals. (This is true as of June 18, 2008.)

However, we have been repeatedly refused such assistance by MRC. The reasons have varied.

In 2003, the first time that I called MRC’s hotline on my folks’ behalf, a recording advised me to leave my name and number, and I received a phone call shortly after, but I was told by that individual that she did not know how MRC could help us. I had called MRC because my (late) mother’s Medicare provider had failed to provide her with medical services that her medical history, including the opinions of the specialists who had seen her, deemed necessary.

I called MRC again in mid 2004, on behalf of both my stepfather and mother for the same reason, and according to the Centers for Medicare and Medicaid Services website:

“Your Medicare Appeal Rights:

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.”

This time I was told via a phone call with MRC’s former Director of Client Services, Rina Kitazawa, that MRC only assists residents of New York State. I informed Kitazawa that in my stepfather’s case, I had found out that the Medicare provider had lied to us about the reason he had been denied a service, but she told me that there was nothing that she could to assist us.

Inexplicably, on or about the fall of 2004, I received a phone call from somebody at MRC saying that somebody was going to be getting in contact with me regarding my stepfather’s case. As it turned out, nobody contacted me.

I wrote a December 12, 2004, letter to Kitazawa asking her to clarify the requirements needed to receive assistance from MRC. I received a letter dated January 14, 2005 that was completely void of fact. Instead of answering my question, for some reason Kitazawa had decided to claim that MRC had carefully examined our case and had determined that we had nothing to appeal!

Earlier, I had provided Kitazawa with documents and testimony that showed that my stepfather’s surgeon (who was employed by the Medicare managed care provider) had requested that my stepfather be given acute physical therapy in my stepfather’s HMO network hospital (which was owned by the Medicare managed care provider) after my stepfather had neck surgery.

I had been told at that time that my stepfather had been evaluated to determine whether he was a candidate for acute physical therapy, and that it had been determined that he was not a candidate.

However, later I found out that he had never been evaluated because according to the Medicare managed care provider, the Medicare managed care HMO would not approve the service because it was “out of network”. (This was a service denial, and thus subject to appeal.) This information had been withheld from his medical records.In her letter to me, Kitazawa knowingly took a position based on the Medicare managed care provider’s deception. Kitazawa refused to acknowledge the documents that showed that a service had been denied.

I have had no further correspondence with Kitazawa. She is no longer at MRC.

The Medicare managed care HMO continued to list MRC as a resource for beneficiaries to use for assistance in filing appeals, and in late 2006, I spoke via a phone call with Paul Precht, MRC’s Director for Policy and Communications in Washington D.C.

Precht informed me that the Medicare managed care HMO was in error for referring its beneficiaries to MRC, but he refused to put that in writing, nor would he allow me to record our conversation.

There are many people, especially those affiliated with MRC, who believe that there is a statute of limitations regarding accountability. I have written to Robert Hayes, President and General Counsel MRC, requesting an explanation, and I have never received a response.

In June 2008, I phoned one of the foundations that grants funds to MRC. I spoke with Barbara Geenburg, President of The Philanthropic Group in New York. According to its website she “designed the grantmaking strategy for the Helen Andrus Benedict Foundation, and directs its grantmaking program.”

I started our conversation by telling her that I was concerned about the manner in which MRC advertised itself. Instead of responding to my concern directly, she asked me why I was talking about something that happened some years ago. I told her that it was because MRC was still allowing the HMO to use its name as a source for assistance. She then told me that she did not think that MRC could get the HMO to stop. I told her that that was ridiculous. She then asked me, as if she were his assistant, if I wanted Hayes to call me. I gave her my phone number, however, I still have not heard from him.

MRC’s promotion of itself has been very successful. Scores of other organizations have also referred me to MRC for assistance with appeals. Some individuals have insisted that I must be mistaken about MRC’s refusal to assist us. One of the reasons MRC’s lack of integrity is harmful is because there are so many people who believe its hype!

In our case, I wasted valuable time contacting and waiting for responses from MRC, because I believed their hype too. There is a need for legitimate resources to be made available to people like us.

The information that MRC offers via its website is available elsewhere on the Internet on sites such as those belonging to WebMD and CMS.

I believe that MRC’s principals hope to keep the donations and grant money coming in by continuing to make false claims about the scope of their assistance to Medicare and Medicare managed care HMO beneficiaries. There is no other reason for them not disclosing the limitations that they have personally disclosed to me.

(MRC’s most recent IRS 990 forms are available for free at GuideStar . Registration is required, but there is no cost to examine the forms.)

Congresswoman Melissa Bean (D-IL, Eighth District) needs to be accountable for herself as well as her congressional staff.

2008-06-22T02:10:00.003-05:00

From Congresswoman Melissa Bean’s (D-IL., 8th District) Campaign Web Site: As part of her ongoing efforts to increase accountability and transparency in congress, Congresswoman Melissa Bean announced a congressional Accountability Initiative at a downtown Chicago press conference Thursday May 28 [2008].

I do not know for whom Congresswoman Bean was doing a favor when she hired Nicholas Jordan to be her Director of Constituent Services, but she was not doing one for herself, and she was certainly not doing one for her constituents. (Jordan worked for Senator Richard Durbin prior to working for Bean.)

In February 2005, on behalf of my stepfather and now deceased mother, I provided Jordan with scores of written testimony and annotated documents, which showed how a Medicare managed care organization had circumvented numerous Medicare regulations with the blessings of Health and Human Services and the Centers for Medicare and Medicaid Services. The fact intensive information that I gave to him was not complicated, but there was a lot of it, and I offered to meet with him if he needed assistance in understanding its significance. Jordan was not enthusiastic about meeting with me, and he did not have an understanding of what a Congressional caseworker may do on behalf of a constituent.

My knowledge of the guidelines for Congressional caseworkers comes from the US House Ethics Committee, as well as other US government publications. This information is readily available via the Internet.

The following statements are from the US House Ethics Committee (Committee on Standards of Official Conduct).

Members and staff of the House often assist constituents in their dealings with administrative agencies by acting as facilitators or "ombudsmen". Members may properly communicate with agencies on behalf of constituents:

* to request information or status reports;
* to urge prompt consideration of a matter based on the merits of the case;
* to arrange for appointments;

* to express judgment on a matter (subject to ex parte communication rules); and/or* to ask for reconsideration, based on law and regulation, of an administrative decision.

The failure of a regulatory agency to enforce its regulations obviously fits into the category of what issues “Members” may inquire about. However, Jordan inexplicably told me that he could not even express judgment about the matter to me, let alone HHS/CMS.

One of the specific violations that I reported to Jordan was that CMS and the Medicare managed care provider had repeatedly denied my stepfather and mother, in a variety of ways, their right to make Appeals, expedited (fast) and otherwise (i.e. due process).

Initially, Jordan was unable to grasp that the issue was not about a judicial matter that I wanted Bean to intervene in. He had trouble understanding that there was no judicial matter because we had been denied access to the regulatory judicial process!

I had told Jordan that I would not turn down any offer of assistance in resolving the matter. However, I also told him that my goal was to convey the wrongdoing that I had encountered to Bean via her staff. I had hoped that somebody in her office would have taken the time to look at the material that I provided to them, and understood what the HMO and CMS had done that was wrong. I thought that this was important, because Bean was going to be voting on Medicare related bills. The Appeals process is the most important safeguard that has been established to protect beneficiaries from having their healthcare compromised by the bottom line of the Medicare managed care insurer and its provider. I had hoped that Bean and her staff would be interested in learning about how CMS was allowing the regulations regarding the Appeals process to be violated. That hope turned out to be wishful thinking.

Jordan eventually mailed a "letter of inquiry” regarding the issue, but:

• He mailed it to the wrong place,

AdminiStar Federal, a company that has a contract with the Federal government to oversee the policies of beneficiaries enrolled directly in Medicare

• He misidentified the issue.

• He failed to provide us with the "answers" that he claimed to have received.

Jordan had told me that he was going to send a letter to AdminiStar Federal. I then had advised Jordan that instead he should direct any correspondence to Matthew Brown, who at that time was the CMS Congressional Liaison in Washington. I explained to him that my stepfather and my mother were Medicare + Choice (now Medicare Advantage) beneficiaries, and CMS itself oversees those policies. Jordan chose to ignore me.

Jordan misidentified the issue as being about the quality of “health care” that had been delivered. It is difficult to understand how Jordan made this error, because I had repeatedly told him that the issue was that Federal regulations had been violated. Bean is not a doctor, and I did not ask her office to become involved in a medical issue.

(By definition, any issues involving the CMS Appeals process will have origins in medical procedures, but I stated in writing to Jordan that I was not asking him to address that issue.)

Because Jordan misidentified the issue as being about the quality of healthcare, AdminStar Federal forwarded the letter from Bean/Jordan to my parents’ Medicare + Choice HMO (the insurer) that had a contract with the Medicare managed care provider). Quality of care issues are formally called Grievances, and at that time were handled internally by the HMO.

Everything that took place next is based on hearsay, as written by Jordan, and his story is absurd. (That is what happens when people do not tell the truth.) He claims that an (as yet) unidentified person or persons at the HMO then voluntarily forwarded the letter to an (as yet) unidentified person or persons at an (as yet) unidentified location at “CMS”. According to Jordan, he then received a phone call from an (as yet) unidentified person or persons from CMS, advising him that the “answers” were the same. Jordon refused to specify what the answers were, or what questions these “answers” were in response to. He won't identify the concerned parties either.

I voiced my concern about this via a phone call with John Gonzalez, Bean’s Chief of Staff, on June 30, 2005. Gonzalez told me that he would look into the matter and get back to me after the Fourth of July holiday, but I did not hear from him again.

It might be unreasonable for Bean to be held accountable for the actions of her caseworker, but she has to be accountable for her chief of staff. Unfortunately, Bean has not been made accountable for much of anything. If Congresswoman Bean is concerned about congressional accountability, she should start by being accountable for herself and her congressional staff.

If our votes count, then Bean should be concerned about losing ours.

---

Note:

The House Ethics Committee has changed its site since I posted this, and I have updated the link.

Illustrations

1. I dropped off the testimony and documents at Bean's office in February 2005, and I faxed this follow up letter to Bean's district office manager in March 2005.

2. The June 16, 2005 letter from Bean with the result of the "letter of inquiry".

3. Nicholas Jordan mailed the "letter of inquiry" to the wrong place (Administar Federal) and misidentified the issue as being about "[health] care".

4. The response letter from Administar Federal to Bean. Because Jordan misidentified the issue as being about the quality of care received by my folks, Administar Federal correctly forwarded it to the insurer. A complaint about the quality of care is a Grievance, and at the time was handled internally by the insurer. Yet, the letter refers to "services" not delivered which is an Appeals issue. If anything, the letter shows that thanks to the people involved, the system consists of nothing but weak links.

If Jordan had correctly identified the issue as being about CMS' failure to enforce its regulations, Administar Federal might have forwarded the letter to the correct location, the office of the Congressional Liaison, in Washington DC.

5. In October 2005, I requested copies of all of the correspondence that had been generated by Jordan's letter of inquiry. I received this letter along with the two previous ones linked to in items 3 and 4. Jordan still would not specify the "answers" that he claimed to have received ex parte from the unnamed person or persons at CMS.

Waiting for a response from the office of Senator Dick Durbin (D-IL) for almost four years

2008-04-22T14:19:00.006-05:00

This letter was faxed on April 22, 2008 to Durbin's Chicago and Washington DC Senate offices. It was faxed again on June 9, 2008, to the attention of "Jennifer" in Durbin's Chicago Senate office. There has been no response as of June 25, 2008. (Only six months until Christmas!)

Update September 22, 2008: Several weeks ago I received a letter from Durbin's policy director, Tom Faletti. As has been the case with most of the employees of the politicians and government agencies that I have corresponded with, Faletti's letter was void of fact. (There must be an epidemic of lower gastrointestinal issues in Washington DC, because most of the information that those people come up with is that which they pull out of their butts.)

I then spoke with Faletti , but he was adament about not wanting to take the time to learn the facts. On top of that, he repeatedly asked me what I wanted him to do, even though I repeatedly told him that the only thing that I wanted him to do was to take the time to learn the facts.

I followed up our conversation with a letter that rebutted his written comments. I will wait a few more weeks to see if he responds, before I post his and my letter.

Letter to Chicago Tribune Editorial Board

2008-03-25T13:48:00.000-05:00

John H. Olsen

March 25, 2008

The Chicago Tribune
attn: Tim McNulty
435 N. Michigan Av.
Chicago, IL. 60611-4041

Dear Mr. McNulty:

For the past four years, I have been trying to share my experience in dealing with my stepfather’s and late mother’s Medicare Advantage HMO and Advocate Health Care (including Lutheran General Hospital), as well as Health and Human Services/Centers for Medicare and Medicaid Services. I have also written numerous letters to “Voice of the People”, none of which were published online or in the paper.

I started overseeing my folks’ health care needs about a decade ago, and became their live-in full-time caregiver in 2000.

Medicare Advantage HMOs have the right to deny specific medical procedures; however, the beneficiaries have the right to make appeals, expedited and otherwise, in response to any denials. Furthermore, according to CMS, a beneficiary can make an appeal simply because they think that they did not receive “an item or service” that they think that they should have received.

Medicare Appeals and Grievances

Your Medicare Appeal Rights:
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. (emphasis mine)

Appeal Rights Under the Original Medicare Plan:
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.

Appeal Rights Under Medicare Managed Care Plans:
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. See your plan's membership materials or contact your plan for details about your Medicare appeal rights.

For more information about the grievance, organization determination, and appeals processes under Medicare Managed Care, see the Medicare Managed Care Appeals & Grievances webpage on the cms.gov website: http://www.cms.hhs.gov/MMCAG

In our case the HMO had subcontracted with Advocate Health Care to deliver the health care, and to also act as an HMO. Advocate circumvented the appeals process numerous times, in a variety of ways, and they did so with the blessing of HHS/CMS.

I have spoken and written about this matter to a slew of politicians, employees of numerous self-described advocacy groups, lawyers, law students, and members of the media. The apathy and ignorance I have encountered has been both troubling and surreal.

The Tribune has endorsed mandatory health insurance. I think that that is one very good reason why somebody at the Tribune should make note of what I have to say. I have a very well documented case to make.

A Tribune editor once commented to me, “Everybody thinks that they have these great stories!”, prior to her blowing me off. One Tribune reporter has always been too busy writing about health care to provide me with an audience, while another reporter simply has not appeared to understand what I was talking about.

A reporter for WBEZ once told me that they would not be interested in one family’s experiences, and thus they would need examples of wrongdoing experienced by others. I told him that he was the reporter, and that since my claims were well documented, he might consider using them as a stepping-stone to look into the matter. I guess that he considered that idea as being too much work.

A reporter for the Sun-Times did not bother to look at the documents that I had sent to her, but she did bother to advise me, “This sounds like an arcane dispute with an insurance company.” That was the dumbest thing that anybody had said to me about the matter, and I told her so. I do not know why any media outlet would want to employ people who are so arrogant. They are merely reporters, and as such one would think that they would not want to cut themselves off from information from “the street”.

There was only one media employee whom I had spoken with that I think had any integrity. He was a Sun-Times editor who quit several weeks ago in response to the layoffs. He had told me that he did not have the financial support to assign such a story. I do not think that he would have needed all of the people that he claimed that he would need, but what he said sounded sincere and thus much different than the [stuff] that I had heard from so many others.

I am not seeking publicity for my folks, but I think that it is important for you to understand that the safeguards that have been established to protect the beneficiaries are not working, thanks mostly to CMS.

Having health insurance is no guarantee that the beneficiary will receive the appropriate health care, and you need to report that…somehow…especially since you are in favor of mandatory health insurance.

Sincerely,

John H. Olsen

cc: all members of the Tribune editorial board.

Update:
No response as of June 23, 2008

Annual B.S. from Center for Medicare Advocacy

2007-12-31T15:08:00.000-06:00

When I contacted the C.M.A. in 2004, they were not interested in hearing about the wrongdoing that I had encountered from the Centers for Medicare and Medicaid Services. They certainly did not offer any assistance to me. In fact, I was told by C.M.A. founder and Director, Judy Stein, that they were only granted to assist residents of Connecticut.

C.MA. claims that they help thousands of people every year in obtaining their Medicare rights.

Each year, the Center represents thousands of individuals in appeals of Medicare denials. The work of the Center includes responding to approximately 7000 telephone and email inquiries each year. We also write extensively about Medicare and related topics, produce a wide array of electronic and hard copy educational materials, advocate in administrative, judicial, and legislative forums, and pursue Medicare coverage for individuals and for dually eligible beneficiaries (individuals who are eligible for both Medicare and Medicaid). In addition, the organization provides legal training and support nationwide as well as for Connecticut's state health insurance and assistance program (SHIP program), known in Connecticut as CHOICES.

Center for Medicare Advocacy web site.

On January 10, 2005, I asked a C.M.A. attorney, Vicky Gottlich, if she had any media contacts that Ishe thought might be interested in my information. Gottlich told me that they did not have any media contacts. The next day I found online, a commentary in the Seattle Post-Intelligencer that she had co-written. The item was titled Medicare agency must be fair, accurate with citizens.

Shortly after that, I discovered that C.M.A. had hired a P.R. firm. C.M.A. is marketed as an organization that helps the general public, when they actually focus on posting redundant information that is available elsewhere on the Internet.

C.M.A.'s major bragging point is a case known as Grijalva Vs. Shalala. In our case, the C.M.S. did not enforce this ruling. However, Stein and Gottlich showed no concern.

Foundation employee contradicts boastful website

2007-11-30T15:09:00.000-06:00

When I searched via Google for "information caregiver" and "caregiver help" I received about 1,280,000 hits for each search. There are countless not-for-profit organizations and government programs that claim to assist and advocate on behalf of caregivers and the individuals who are being cared for.

The following statement is from one of the sites - the National Family Caregivers Association - that my search found.

...Family caregivers have been invisible and silent far too long. NFCA works hard to give a collective voice to all family caregivers and supports the development of sound public policies which can support care giving families nationwide.

The site boasts the same claims that are made on other websites, many of which are linked to on the NFCA links page. However, when contacted, a staff member only spoke about how small and powerless NFCA is.

The following is what the NFCA writes about...the NFCA.

NFCA is a grassroots organization created to educate, support, empower and advocate for the millions of Americans who care for chronically ill, aged, or disabled loved ones. NFCA is the only constituency organization that reaches across the boundaries of different diagnoses, different relationships and different life stages to address the common needs and concerns of all family caregivers. NFCA serves as a public voice for family caregivers to the press, to Congress and the general public. NFCA offers publications, information, referral services, caregiver support, and advocacy. (Emphasis mine)

The NFCA staff member was unaware of these statements. She was confused as to why I would want to offer testimony regarding the problems that I have faced as a caregiver. NFCA can not serve "as a public voice for family caregivers to the press, to Congress and the general public", if its staff chooses to ignore the more complicated problems that caregivers encounter.

Is there a fee for NFCA serving as a "public voice"? Does this site merely exist to sell books and other information?
http://www.nfcacares.org/nfca_store/nfca_publications.cfm

The following is a link that explains how to become a NFCA corporate sponsor.
http://www.nfcacares.org/corporate_partner/

The individual at NFCA refused to identify herself. At one point she claimed that there are only "four of us here". The following is a link to the "board and staff" page of NFCA's website.
http://www.nfcacares.org/about_nfca/board_and_staff.cfm

Note that Corrine Parver is listed as being NFCA's Director, and that she had been the head of (law firm) Dickstein, Shapiro, Morin & Oshinsky's Health Care Law Services. This is how the firm's web site defines its Health Care Law Services: provide a full range of legal services to health care providers, manufacturers, corporations, trade/professional advocacy; litigation; and other general health care legal and reimbursement matters.

The most recent NFCA IRS 990 form available is from 2004.
http://www.nfcacares.org/pdfs/NFCA_2005_990.pdf