You can’t get there from here……

For October, I wanted to write about something really scary. I picked Medicare.

One of Medicare’s absurd rules is how to transport the infirm. They will pay for transport from facility to facility, but they will not pay for transport from your home to any medical appointment or hospital test (mostly). So, if you are completely wheelchair bound, like my brother-in-law, have no use of your legs, and your doctor orders a CAT Scan or MRI, or even the lowly X-ray, you:

A.  Can’t get there

B.  Can’t get ON the table when you get there

C.  Better have a bucket of cash stowed somewhere to pay for private transport

After days, weeks and months of figuring out the rules, and hacking at the system. I found that if my brother-in-law’s medical appointment required that he be in the upright position ( meaning sitting in his wheelchair…..and his tray table up, presumably) he had to pay for an ambulance. If, however, he needed to get on to a medical table for any kind of test and the test was at a hospital, then Medicare would pay for the transport.

This is how I found that out.

Medicare denied payment of  transport for a CAT scan. I followed all the rules, contacted all the right people. Got all the pre-certs, the approval numbers and the referrals. I scheduled the scan and ambulance using the information the insurance company gave me.

Several weeks later, an Explanation of Benefits flew into my mailbox like a brick through the front window. Payment Denied. I made a thousand phone calls, appealed the decision, twice, and was still denied as transport was not an emergency or medically necessary. Because why would it be medically necessary for someone who can’t walk and can’t get on an examination table to have gurney transport and EMT’s lift you up on to the table? Surely, you can find a way to hoist yourself out of that wheelchair, my good man.

Now I had to appeal to an Administrative Law Judge.  Short of asking the ALJ to come to my brother-in-law’s apartment and see how the hired caregivers get him ready for the day, I was pretty sure I needed a unique approach.

Yay….social media…..Yay….youtube.I was inspired.

With my brother-in-law’s approval, I took that amazing little iPhone and made a movie of  two caregivers dressing him, washing him, lifting him out of his bed with a mechanical lift and into his wheelchair, combing his hair,  helping him brush his teeth and shave, and giving him a nice pat on the head to have a good day.

I made a copy of the video, put it on a CD (yeah the Medicare appeal system isn’t that tech savvy that I could upload it), mailed it to the judge, and waited.

Lo and behold after 3 hearing cancellations by the insurance company, I got a phone call from the judge’s office saying that the insurance company had agreed to pay the claim and there would be no hearing.

I take a bow and accept my Oscar for best performance by  a caregiver in a horror film. Pretty scary, huh?

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8 thoughts on “You can’t get there from here……”

  1. It is, indeed, an amazing job. I read just last week that when Medicare was first formed it was pretty open to the needs of the patients, but as time went by it got more and more strict and bureaucratic. Probably a lesson to be learned in that.

  2. Good for you Cathy! You are so right, the entire medical industry and health care system is VERY SCARY. I do think there are some tiny steps in the right direction but it is so messed up it’s hard to imagine whether it will ever be right. Meanwhile, taking things into your own hands was the BEST SOLUTION ever!

  3. You have a great talent for using humor in a respectful way even in the most difficult situations. I hate insurance companies and yet, people still want to hold onto this system.

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