A Patient Advocate's View

Exceptions to the rule

images9VWBAIKZ     I had an interesting issue with Guildnet yesterday, one of the Managed Long Term Care Plans (MLTCP) This is not a case of someone trying to get something for nothing. This patient worked all his life and paid into the system that is supposed to protect him now that he needs help. After a battle with throat cancer, he is cancer-free but the radiation treatments burned his esophagus so that he needs a feeding tube and suffers now from recurring aspiration pneumonias. He also has chronic gerd and has lost so much weight that he can hardly hold himself up.
The patient was being interviewed to determine how many hours he would get for home care services covered by Medicaid through the MLTCP. Everything was going well and the patient was approved for 18 hours a week, which we decided to take as 3 hours 5 days a week. However, when we talked about the feeding tube supplies and oxygen he needed, which were covered by Medicare, a problem came up. His doctor spent months finding a small  oxygen pack that he could carry. He is very frail but not in a wheelchair. Guildnet only contracts with one provider of oxygen.  We already knew that this company only carries the large green “portable” bottles that are made for wheelchairs, not for carrying. The nurse said that she was told to turn people down from the plan if they were not willing to change to a contracted DME provider. I called Ilene Greinsky, Eldercare Resources. I asked her if this could be correct. She advised the nurse to call administration and ask for an exception.  The nurse was hesitant and decided not to continue the enrollment until the problem was solved. Of course we were very disappointed as the patient had been waiting for months to get some help.  I called Paula Goodstein,  Geriatric Resource Consultants, who had prepared the original Medicaid application and had set up the Guildnet meeting. She was able to find out that since the DME provider did not have the item the patient needed, then Medicare would continue to pay for the item and the MLTCP would pay the co-pays.
What a messed up system. After we settled in to look at the mail, I found that two of the patient’s medications were not on the formulary for Silver Scripts, the new Medicaid Drug plan in which he has been automatically enrolled. The patient was given a 30 day emergency supply. Now, his doctor must send supporting documents to show why the patient needs this medication, instead of another similar medication on the formulary, of which there are none.
To top it off, the hospital sent a bill for a visit 6 months ago that they say was rejected by his insurance. A call to them showed that they had sent his claim to the wrong insurer. And last but not least, his stay at the rehab facility after the hospitalization has been denied coverage.  The reason I was referred this case was because the rehab had been notified that the patient was reaching his maximum coverage in a week and needed to be discharged. So, if they had the maximum coverage letter, they must have had the coverage letter for the previous 100 days he was there. Right?

May 18, 2016 Posted by | Uncategorized | Leave a comment