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

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 had a chance to look at them. 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.

When it comes to overseeing the health care needs of others, it is difficult to be vigilant without being a pain in the ass. This was the case with Advocate. 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 what 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 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 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 3 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 weeks 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 this slop, so I started bringing food in from the outside when I saw him.

My stepfather received physical therapy about 5 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 days when he did not have PT at all. He never regained his strength or weight while at Warren-Barr.

I spoke with Nancy Meyers, the Advocate nurse attending to my stepfather, about this. At the beginning of August 2003, she mentioned that my stepfather was not doing well in therapy, and that he would probably have his benefit suspended soon. My bypass surgery had already been postponed several times by this point, 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 been saying that he may never walk again, and so he needed somebody to care for him while I recuperated. (for example, I was not supposed to lift anything heavy so my chest could heal.)

I was finally scheduled for my surgery to take place on August 20, 2003. On August 18, 2003, I spoke with Myers about my stepfather and his progress. I asked her what the earliest date would be when he would have his PT terminated. She told me August 29, 2003 (eight weeks from when it started).

My August 20 surgery was again postponed...on August 20. Advocate had no way of knowing this. That morning, I received a call from a friend whose number I had given out for emergency purposes. Somebody from Warren-Barr had called him and had told my friend that my stepfather's PT was going to be terminated on August 22, 2003, and they wanted to know where my stepfather would be going. After hearing, this I immediately called Dr. Rajan Raj, his surgeon, and he told me that the PT that my stepfather had received had not been adequate. I asked if he would put that in a letter, and told me that he would. (However, it took about four months before he wrote one.)

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 14 days, in order to give time for me to obtain the surgeon's input.

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. 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 not being covered by insurance. However, he was being shorted one week anyway, so we should have succeded in having the termination delayed for at least 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 Advocate 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 this act of contempt toward us.

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

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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.

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.

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.

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.

Page one

Page two

Page three

Page four

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.

Advocate Health Care has non-profit status. That's little consolation to my stepfather. However, it does mean that Advocates 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 the CMS regulations. He refused to

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

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.