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
Tuesday, March 25, 2008
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