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.
