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!
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.)
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.
