Most of our aging parents receive Medicare, which is supposed to pay “covered medical costs”. And for the most part, it does. But then there are the mistakes. Are your aging parents helpless when Medicare refuses to pay for something that appears very legitimate? They get a bill for something that is supposed to be covered but instead shows that Medicare covered none of it and your aging parents are responsible for the full amount. Maybe you, the adult child will get a call about this. Here’s what you need to know about wrongful Medicare denials. Not taking action can leave an aging parent with a big bill, which they should not be forced to pay. They are not without recourse. But for an aging loved one, someone else may need to get involved to help them fight back when Medicare makes a mistake.
Medicare is a massive system and when anything that big is run by humans who make errors, sooner or later an expensive mistake can hit your aging parents. It happened in my own family and it is worth sharing how we prevailed in a dispute that should never have happened.
95-year-old Alice, who lives in a seniors’ apartment and normally functions independently was having trouble. She had recently had a bout of pneumonia that landed her in the hospital, close call for anyone that age. She recovered but had a scary memory of what it felt like to have trouble breathing. She was just getting back to her normal routine. Things were stable. But one night she awoke gasping for breath. Trying not to panic, she pressed her emergency alert button on her pendant (which we had finally convinced her to wear!) and the paramedics were summoned. They promptly took her to the ambulance, started oxygen and an IV and rushed her to the emergency department of the nearest hospital. She was admitted, treated, and after a few days she returned home. All seemed ok. Until the ambulance bill came. Medicare denied payment of it for no apparent reason.
Medicare does cover ambulance bills under most circumstances, as well as all ER treatment and the hospitalization itself. That is what the premiums pay for. She had never had this kind of trouble from Medicare before. We got involved because she was frustrated and upset over it. Here’s what family needs to know:
- Anyone whose bill is denied by Medicare has a right to appeal the decision. Medicare is required to give the person a letter with the denial, explaining the right to appeal.
- The appeal process is tedious, makes little sense and is likely to result in another denial or two. You have to follow the steps in the Medicare letter exactly and persist. This is where the family can help.
- With a legitimate bill, like the ambulance bill, Medicare can come up with any screwy basis for the denial they wish to use. In her case, they seemed to imply that she could have gotten to the ER by magic carpet or taxi or some other ridiculous means when she was gasping for breath. Dumb reason.
- Persist and ask for a hearing after the next denial. Again, Medicare must inform you in writing of the right to ask for a hearing. It takes place by phone. The judge does not read all about it before taking testimony from the Medicare recipient. After hearing the testimony by phone, the judge then reads what was submitted by the Medicare recipient after the first and second rounds of denial. In Alice’s case that was proof of her diagnosis and admission to the hospital that night as well as a letter from her son, my husband. Alice did just fine. She told the judge what happened after being prepped the day before by us. Telling the truth is not difficult.
- The result from a hearing is much more likely to be successful than submitting written proof prior, as we did, that the bill was legitimate. You have to do it to make a record, but perhaps no one actually looks at it during that stage of this process. The judge is required to read the material and presumably considers it. With the earlier repeated denials, one would think that the proof had been submitted to a robot programmed to an automatic “no”.
Medicare has endless rules and ways to deny payment for lots of things ordinary people think should be covered. The takeaway from this is that our aging loved ones are vulnerable to unreasonable denials of legitimate claims to Medicare and that they may need our help in navigating the appeal process. Alice simply could not have managed this journey by herself. She got confused by the letters. She got mad because she really needed the ambulance that night and how dare they say she didn’t?
She didn’t know what to do. With our help she prevailed. We were quite happy that the judge at her hearing got it and did the right thing. The process was a pain. But with it, the bill was paid in full. Have you had this situation or something similar occur with your aging parents? We’d love to hear your story. Comment here or email us: firstname.lastname@example.org
To learn more about how you can become an advocate for your aging loved one, check out our book: The Family Guide to Aging Parents.