Insurer Stonewalls on $16,500 Claim for Home Care for invalid before he dies

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Nov 7, 2018
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#1
A major health insurer has spent one year "reprocessing" a $16,500 claim for short-term home care for a Medicare-covered patient in home hospice who was also covered by the insurer's Senior Executive Plan. Home care was provided during the 3.5 weeks after the patient fell and became an invalid with broken nose, neck and more, just before he died in California on November 2017. The insurer has not officially decided on or reimbursed the $16,500, which I paid for, out of pocket, to the licensed home-care agency.

The insurer initially requested medical codes that the home-care agency insists they are not legally able to provide, since they don't provide medical services—only home care. The care was supervised by home-hospice nurses and staff and carried out by the home-care agency. I've submitted over 600 pages of dr., hospital, hospice and home-care agency records, including excerpts with specific pages pointed out that show medical codes, detailed treatment and care plans. The insurer now appears to be seek a technicality in order to deny the claim.

It may be a coincidence, but after a year of delays, I recently snail-mailed the CEO. Days later, the claim was bumped up from the "reprocessing" bin and is now with the Senior Resolution Team, who called me on the phone. I finally had some hope when I was recently asked for proof that I was the executor of the patient's estate.

But soon after submitting trust documents, another surprise: it took one year for the insurer to inform me that they require a Medicare Explanation of Benefits. Yet the insurer is fully aware that Medicare never covers short-term home care. So far I have found no Medicare Explanation of Benefits for this period of home-care services (I'm in NY and the patient lived in California.)

Question: can the insurer use the requirement for a Medicare Explanation of Benefits as grounds to deny a claim they've been stonewalling on for a year—when I was never asked for this document until a year after first submitting the claim? A layperson not familiar with Medicare regs, I could have avoided a year of bureaucratic struggling to get information and records if only the insurer had requested this from the beginning.

Many thanks for your thoughts!
 

jsn55

Verified Member
Dec 26, 2014
7,317
7,139
113
San Francisco
#3
This will take an insurance ombudsman, it's an awful story and way over our pay grade. I do know that insurance companies spend a great deal of time and effort to be as obtuse as possible, hoping to wear you down so you'll just give up. I'd start with Medicare and see if they can point you towards to an agency or community service who are familiar with this situation and can guide you.
 
Feb 3, 2017
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#4
Hospice does not provide medical care - Was the patient in hospice or receiving medical care from the home care agency? If this was a hospice situation, there should be no costs; but, there would be for a home health care agency. I agree, you probably need an attorney or an advocate who specializes in such situations. (My mother and father both had hospice at home and never incurred any charges - they lived in Los Angeles). You have referred to both types of "care" - was it one or the other or at some point, it just became hospice care?
 
Feb 3, 2017
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#5
This will take an insurance ombudsman, it's an awful story and way over our pay grade. I do know that insurance companies spend a great deal of time and effort to be as obtuse as possible, hoping to wear you down so you'll just give up. I'd start with Medicare and see if they can point you towards to an agency or community service who are familiar with this situation and can guide you.
True - here in NYC I know of a few such services that would assist in this sort of confusing matter but I don't know any in California.

Here is someone you might contact to see if he can direct you to someone appropriate to speak to - https://www.consumerwatchdog.org/users/jamie-court -- He's been working on health care issues for years and may well know a good source for you; no guarantees, of course, but he would be my first port of call if I was in California still.
 
Likes: jsn55
Sep 19, 2015
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#6
Was the home care skilled care?

Is this a Medicare B insurance?

Or is this a specific additional policy?


How often is it covered?
Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) covers eligible home health services like these:
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare doesn't pay for:
  • 24-hour-a-day care at home
  • Meals delivered to your home
  • Custodial or personal care (help bathing, dressing, and using the bathroom) when this is the only care you need

There is too little information on a complex issue.

A secondary insurance can ask that the claim be submitted to the primary insurance first — this is prevent people from being paid twice (ie double dipping).
 
Jun 30, 2017
849
785
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Maui Hawaii
#7
A major health insurer has spent one year "reprocessing" a $16,500 claim for short-term home care for a Medicare-covered patient in home hospice who was also covered by the insurer's Senior Executive Plan. Home care was provided during the 3.5 weeks after the patient fell and became an invalid with broken nose, neck and more, just before he died in California on November 2017. The insurer has not officially decided on or reimbursed the $16,500, which I paid for, out of pocket, to the licensed home-care agency.

The insurer initially requested medical codes that the home-care agency insists they are not legally able to provide, since they don't provide medical services—only home care. The care was supervised by home-hospice nurses and staff and carried out by the home-care agency. I've submitted over 600 pages of dr., hospital, hospice and home-care agency records, including excerpts with specific pages pointed out that show medical codes, detailed treatment and care plans. The insurer now appears to be seek a technicality in order to deny the claim.

It may be a coincidence, but after a year of delays, I recently snail-mailed the CEO. Days later, the claim was bumped up from the "reprocessing" bin and is now with the Senior Resolution Team, who called me on the phone. I finally had some hope when I was recently asked for proof that I was the executor of the patient's estate.

But soon after submitting trust documents, another surprise: it took one year for the insurer to inform me that they require a Medicare Explanation of Benefits. Yet the insurer is fully aware that Medicare never covers short-term home care. So far I have found no Medicare Explanation of Benefits for this period of home-care services (I'm in NY and the patient lived in California.)

Question: can the insurer use the requirement for a Medicare Explanation of Benefits as grounds to deny a claim they've been stonewalling on for a year—when I was never asked for this document until a year after first submitting the claim? A layperson not familiar with Medicare regs, I could have avoided a year of bureaucratic struggling to get information and records if only the insurer had requested this from the beginning.

Many thanks for your thoughts!
How is the patient related to you? Why did you pay the charges for care? Why did you feel you were responsible for the charges? Medicare pays home hospice for care rendered. The patient's estate is responsible for charges rendered.
 

JVillegirl541

Verified Member
Nov 21, 2014
3,330
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#8
Bottom line they need you to submit the claim to Medicare and need a Letter of Denial in order to process your claim. Medicare is the Primary Insurance carrier and you are filing a claim with the Secondary Coverage Insurance Carrier. They need a Denial from your Primary Insurance Medicare. Yes we all know Medicare won’t pay but getting the letter is standard practice.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
14,700
13,757
113
New York
www.promalvacations.com
#10
Bottom line they need you to submit the claim to Medicare and need a Letter of Denial in order to process your claim. Medicare is the Primary Insurance carrier and you are filing a claim with the Secondary Coverage Insurance Carrier. They need a Denial from your Primary Insurance Medicare. Yes we all know Medicare won’t pay but getting the letter is standard practice.
There are further complications here - we don’t know the relationship between the insured and the OP- if OP isn’t related to or has POA on the estate of the person who was insured - Medicare isn’t going to deal with him or her.

Our writer needs an attorney.
 
Likes: jsmithw
Feb 3, 2017
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#11
When dealing with both in home care services prescribed by my parents' physicians (some nursing, PT, etc), the service providers submitted billings to Medicare and then we would receive Medicare's Explanation of Benefits and what they would pay for and the supplemental plans would also inform us of what, if anything, they would pay for. We never paid out of pocket first then submitted for reimbursement.

This situation where the OP says he/she paid out of pocket to the agency is curious because it sounds like he/she then attempted to get reimbursed in a manner that is different than usual practices with Medicare, prescribed home care services, etc.

Too - there is not clarity if this was all hospice (for which there would be no billing/costs) or what exactly.

I agree - an attorney or someone (service agency which provides assistance with these complex matters) is needed.
 
Feb 3, 2017
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#12
There are further complications here - we don’t know the relationship between the insured and the OP- if OP isn’t related to or has POA on the estate of the person who was insured - Medicare isn’t going to deal with him or her.

Our writer needs an attorney.
The OP does make reference in the original post as to being the Executor of the estate of the deceased so, presumably, OP is in a position to deal with the matter with any obstacle.

Also, it seems, though I am not certain I am fully understanding the OP that he/she did not have communication for a full year after sending in evidence of being Executor.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
14,700
13,757
113
New York
www.promalvacations.com
#13
If the OP is Executor of the Estate- them he or she should already be dealing with an attorney. The attorney should be assisting but an Elder Care specialist might be needed.

My mother in law was on hospice care at home for three years (yes, years- they never expected her to live more then six month but having the extra care kept her alive for three years- the longest the nursing company ever had anyone on hospice care) and never paid a penny out of pocket. The nursing care company handled everything with Medicare. I’m not sure why this wasn’t done right from the beginning.
 
Feb 3, 2017
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#14
If the OP is Executor of the Estate- them he or she should already be dealing with an attorney. The attorney should be assisting but an Elder Care specialist might be needed.

My mother in law was on hospice care at home for three years (yes, years- they never expected her to live more then six month but having the extra care kept her alive for three years- the longest the nursing company ever had anyone on hospice care) and never paid a penny out of pocket. The nursing care company handled everything with Medicare. I’m not sure why this wasn’t done right from the beginning.
Hence, the reason needed for clarity as to whether this was a purely hospice situation or in-home health care was provided. The OP paying out of pocket then seeking reimbursement is the confusing (or, one of them) aspect of this situation.

I do know of an Elder Care advocate service but it is here in NYC, not in California.
 
Likes: Neil Maley
Jun 30, 2017
849
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93
Maui Hawaii
#15
The OP does make reference in the original post as to being the Executor of the estate of the deceased so, presumably, OP is in a position to deal with the matter with any obstacle.

Also, it seems, though I am not certain I am fully understanding the OP that he/she did not have communication for a full year after sending in evidence of being Executor.
The OP is the executor but that does not in any way explain why they paid "the $16,500, which I paid for, out of pocket, to the licensed home-care agency. "
The executor is not liable personally for payment of any pre- or post-death expenses. The estate is. The OP/executor should also consult an attorney as he may be due payment of the $16,500 from the estate.

Also to clarify, Medicare provides payment for many types of home care when ordered by a physician. Whether the care provided is covered is not possible to determine. Medicare also covers home hospice care. If this patient received home care that consisted of personal care such as bathing, dressing, and feeding, it is possible that no insurance would have covered this type of care as it is not "medical".
 
Likes: Neil Maley
Jun 30, 2017
849
785
93
Maui Hawaii
#16
If the OP is Executor of the Estate- them he or she should already be dealing with an attorney. The attorney should be assisting but an Elder Care specialist might be needed.

My mother in law was on hospice care at home for three years (yes, years- they never expected her to live more than six months but having the extra care kept her alive for three years- the longest the nursing company ever had anyone on hospice care) and never paid a penny out of pocket. The nursing care company handled everything with Medicare. I’m not sure why this wasn’t done right from the beginning.
I think that the " short-term home care " may be personal care such as feeding, dressing, and bathing in addition to the care provided by home hospice. This type of care is probably not covered by Medicare or any Medicare supplement. Why the OP paid for this from their personal funds is not clear, but they are probably eligible for repayment from the estate if there are funds available.
 

Neil Maley

Moderator
Staff Member
Advocate
Dec 27, 2014
14,700
13,757
113
New York
www.promalvacations.com
#17
I think that the " short-term home care " may be personal care such as feeding, dressing, and bathing in addition to the care provided by home hospice. This type of care is probably not covered by Medicare or any Medicare supplement. Why the OP paid for this from their personal funds is not clear, but they are probably eligible for repayment from the estate if there are funds available.
My mother in law had an aide that came in three times a week through hospice that did just this type of care- she helped her shower, did light cleaning in the house and prepared lunch. And a nurse came in every other week. And all of her medications she was prescribed during this were also fully paid for. All were covered by Medicare.

This just doesn’t make sense as to why this was paid for out of pocket since Medicare does cover hospice home care nor why an attorney isn’t helping. I am wondering if the company that provided the nursing services didn’t file the paperwork properly so that
Medicare paid.
 
Jun 30, 2017
849
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Maui Hawaii
#18
My mother in law had an aide that came in three times a week through hospice that did just this type of care- she helped her shower, did light cleaning in the house and prepared lunch. And a nurse came in every other week. All were covered by Medicare.

This just doesn’t make sense as to why this was paid for out of pocket nor why an attorney isn’t helping.
Hospice will cover the type of care (3X/wk by an aide, ~12 hrs/wk total) you have described for your MIL, but the size of the bill ($16,500) for 3.5 weeks suggests 24 hr home care from a personal aide. The description of the patients status " invalid with broken nose, neck and more " would indicate a bedridden individual who could not be left alone at all. This type of care is probably not going to be covered by Medicare or other insurance. Many severely ill people are cared for at home by the family with the addition of personal care not covered by insurance. This case may be one such case.
 
Apr 10, 2017
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#19
Hospice will cover the type of care (3X/wk by an aide, ~12 hrs/wk total) you have described for your MIL, but the size of the bill ($16,500) for 3.5 weeks suggests 24 hr home care from a personal aide. The description of the patients status " invalid with broken nose, neck and more " would indicate a bedridden individual who could not be left alone at all. This type of care is probably not going to be covered by Medicare or other insurance. Many severely ill people are cared for at home by the family with the addition of personal care not covered by insurance. This case may be one such case.
That is correct. My mom has dementia and is bedridden. My dad really wants her to be home with him so my siblings and I chip in to cover home health to come in a few times a day. She doesn't need 24/7 care but this isn't covered by their insurance, which happens to be a very good Medicare plan.
 
Likes: jsn55
Feb 3, 2017
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#20
The OP is the executor but that does not in any way explain why they paid "the $16,500, which I paid for, out of pocket, to the licensed home-care agency. "
The executor is not liable personally for payment of any pre- or post-death expenses. The estate is. The OP/executor should also consult an attorney as he may be due payment of the $16,500 from the estate.

Also to clarify, Medicare provides payment for many types of home care when ordered by a physician. Whether the care provided is covered is not possible to determine. Medicare also covers home hospice care. If this patient received home care that consisted of personal care such as bathing, dressing, and feeding, it is possible that no insurance would have covered this type of care as it is not "medical".
That is what I am stuck on - Medicare does cover certain such care if prescribed but as to why the OP paid out of pocket then, seemingly submitted for reimbursement, is a curiosity - to me - as of now.