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

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Feb 3, 2017
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#21
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.
It may be the case that the patient was initially receiving in-home care prescribed by the physician and OP paid for the round the clock care the patient may well (likely) have required (which is not covered) and then transitioned into hospice over time. Well, until OP returns if he/she does, I will remain confused.
 
Likes: Neil Maley

Neil Maley

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#22
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.
I agree. I don’t understand why the patient wasn’t kept in a nursing home or hospital if they were in such bad physical condition.

I am not sure in home hospice care is what was actually provided-it sounds more like exactly what you are describing which is not covered and unless the estate has money Salsera me not be reimbursed period.
 
Jun 30, 2017
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Maui Hawaii
#23
I agree. I don’t understand why the patient wasn’t kept in a nursing home or hospital if they were in such bad physical condition.

I am not sure in home hospice care is what was actually provided-it sounds more like exactly what you are describing which is not covered and unless the estate has money Salsera me not be reimbursed period.
Given the information provided, inpatient hospice care would have been appropriate if available.
 
Likes: Neil Maley
Nov 7, 2018
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#27
Dear Neil,
Possibly GOOD NEWS due partly to all of you! I spoke with insurer and mentioned that unfortunately, I've had to contact Consumer Advocate Christopher Elliott's staff — that may have helped considerably! I confirmed that:

1. Insurer did formally deny the very large claim—but not on the grounds that a Medicare Explanation of Benefits hadn't been submitted. (It took a full year for them to request that—a brand-new hurdle. Claim had been denied on the grounds that further information was needed, though they've had 600+ pages of records for a year.

I mentioned that I believe the request for the Medicare EOB is disingenuous: insurer knows full well that Medicare never covers short-term home care.

2. They've now put up yet one more hurdle. But luckily, an extremely helpful Senior Resolution Team rep is personally in touch, offering her phone # and email. Could be in part thanks to you! We'll see. THANK YOU for. your prompt help. Cheers!
 
Nov 7, 2018
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#28
P.S. Does anyone know the meaning of this indication in Claims Remarks, which show a health insurer's reasons for claim denial:"[E73 - for administrative use only].
Is this universal—or is it proprietary (and discrete) info for the administers of this particular health insurer? Many thanks!
 

Neil Maley

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Dec 27, 2014
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www.promalvacations.com
#29
P.S. Does anyone know the meaning of this indication in Claims Remarks, which show a health insurer's reasons for claim denial:"[E73 - for administrative use only].
Is this universal—or is it proprietary (and discrete) info for the administers of this particular health insurer? Many thanks!
That is something you would need to ask the person you are working with.

Can we ask why they didn’t leave this person in the hospital or send him to a nursing home? Does the secondary policy actually cover short term care? In many of these instances, it’s all out of pocket.

Since you are the executor- can’t the attorney handling the estate help with this?
 
Likes: Christina H
Sep 19, 2015
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#30
I agree with Neil. As no one has access to the papers we should not be guessing.

Being an Executor is a responsibility with legal and fiduciary obligations. The Executor is paid from the Estate and the Executor should consult professionals — specialists in law or health care billing— what ever the questions are.

It is not that I do not want this to work out well for Salsera— an elderly person was able be at home for the final months and hopefully that was more comforting than a hospital.

There are many reasons why the OP may have paid — one being to have the immediate service and maybe the elderly person did not have anyone with Power of Attorney or Co-Signer — maybe the elderly person was house rich and cash poor— which happens.
 
Likes: Neil Maley
Feb 3, 2017
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#31
Thankfully, it seems posters have been very careful not to be guessing - more mulling over the original post, puzzling out what the situation might have been - but, all have been (from what I read) suggesting OP seeks assistance on this matter from an appropriate resource.

This whole arena of medical care, billing, codes, explanations, in-home care, hospice, etc is so complex it really does require specific expertise to work this through with care.
 

jsn55

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Dec 26, 2014
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#32
Thankfully, it seems posters have been very careful not to be guessing - more mulling over the original post, puzzling out what the situation might have been - but, all have been (from what I read) suggesting OP seeks assistance on this matter from an appropriate resource.

This whole arena of medical care, billing, codes, explanations, in-home care, hospice, etc is so complex it really does require specific expertise to work this through with care.
Very glad that this case is seemingly moving forward. I'm curious about all the posts stating that there's no charge for hospice. What does that mean? I only know that hospice happens at home when someone is not going to recover and there's no more treatment. Who administers it? Who's in charge of it? Does it happen through a church or an agency?
 
Feb 21, 2018
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#33
Very glad that this case is seemingly moving forward. I'm curious about all the posts stating that there's no charge for hospice. What does that mean? I only know that hospice happens at home when someone is not going to recover and there's no more treatment. Who administers it? Who's in charge of it? Does it happen through a church or an agency?
Actually, hospice does not always happen at home.

When my father's health took a drastic turn in January of this year it was time to follow his directive, cease medical intervention and put him in the care of hospice. He stayed right at the hospital, albeit in a different section that was defined as the 'Hospice'.

He was officially 'discharged' from normal hospital care after the hospice papers were signed and his DNR bracelet affixed. As soon as a bed on the hospice section became available he was moved from the medical floor and taken down two floors to a large private room with a dedicated hospice nursing staff and standing orders to administer only meds to ease pain and to handle all personal care needs. Family was permitted to stay 24 hours/day.

All care was handled by licensed nurses. A staff physician wrote all orders for pain relief ahead of time, eliminating the need of a nurse to say "Let me call the doctor and check". We were told that, depending on how long he was a patient of hospice, he would be carefully bathed each and every day by the nurse, who would provide any other assistance the family requested regarding his care.

100% of the cost of his time in the hospice section was covered fully by Medicare. It was the calmest and most peaceful 32 hours of his entire stay.

We were grateful for this option rather than home hospice. The event of having him at home, so ill and then passing, might always associate that memory with the home my mother still lives in.
 
Likes: AMA
Jun 30, 2017
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Maui Hawaii
#34
Very glad that this case is seemingly moving forward. I'm curious about all the posts stating that there's no charge for hospice. What does that mean? I only know that hospice happens at home when someone is not going to recover and there's no more treatment. Who administers it? Who's in charge of it? Does it happen through a church or an agency?
Medicare pays 100% of hospice care costs, inpatient or outpatient.
 
Feb 3, 2017
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#35
The physicians for both of my parents made the arrangements with hospice; both wanted to be at home and so hospice people came to do as described above and as they worsened, the more time they would spend ensuring they were comfortable. They will not provide medical care but will administer - in their case - some morphine to ease the pain and make them as comfortable as possible - which they did.

Many hospitals have designated parts that are specifically for hospice patients.

A discussion with your physician or physician for someone in your family (or whatever the relationship) at a time when the diagnosis is terminal will help you through the process but they really do pretty much everything. They took care of calling the funeral home and called Social Security to let them know, arranged to pick up equipment we had had delivered to the house, etc. They are really remarkable individuals who do this sort of work -
 

Neil Maley

Moderator
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Advocate
Dec 27, 2014
14,700
13,757
113
New York
www.promalvacations.com
#36
The physicians for both of my parents made the arrangements with hospice; both wanted to be at home and so hospice people came to do as described above and as they worsened, the more time they would spend ensuring they were comfortable. They will not provide medical care but will administer - in their case - some morphine to ease the pain and make them as comfortable as possible - which they did.

Many hospitals have designated parts that are specifically for hospice patients.

A discussion with your physician or physician for someone in your family (or whatever the relationship) at a time when the diagnosis is terminal will help you through the process but they really do pretty much everything. They took care of calling the funeral home and called Social Security to let them know, arranged to pick up equipment we had had delivered to the house, etc. They are really remarkable individuals who do this sort of work -
This is the exact scenario we had with my in-laws. The family was shown how to administer the morphine. But my mother-in-law became very combative and the family couldn’t handle her at the end and they had to move her to a hospice center where the nurses and doctors administered meds to keep her sedated.

The folks that do this type of works are so wonderful with the patient and also help the family through the end of life stages. I know my wife and her brothers and sister were very grateful for the care given to their mother.
 
Jun 30, 2017
849
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Maui Hawaii
#37
The physicians for both of my parents made the arrangements with hospice; both wanted to be at home and so hospice people came to do as described above and as they worsened, the more time they would spend ensuring they were comfortable. They will not provide medical care but will administer - in their case - some morphine to ease the pain and make them as comfortable as possible - which they did.

Many hospitals have designated parts that are specifically for hospice patients.

A discussion with your physician or physician for someone in your family (or whatever the relationship) at a time when the diagnosis is terminal will help you through the process but they really do pretty much everything. They took care of calling the funeral home and called Social Security to let them know, arranged to pick up equipment we had had delivered to the house, etc. They are really remarkable individuals who do this sort of work -
It is important to clarify some terms being used in this thread. Hospice/home/comfort care including nursing care and medications is "medical care" and must be ordered by a physician. It is not curative/restorative care but is certainly "medical care". Home health aide care is not medical care.
 
Apr 23, 2018
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#38
Back to the OP's original problem - the seemingly stonewalling insurance company: She lives in New York State and perhaps is not familiar with the California Department of Insurance. It may well be that she needs the assistance of a lawyer or specialty advocate, but I recommend she first familiarize herself with what services are available through the Department.
http://www.insurance.ca.gov/01-consumers/
 
Sep 26, 2017
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#39
Actually, hospice does not always happen at home.

When my father's health took a drastic turn in January of this year it was time to follow his directive, cease medical intervention and put him in the care of hospice. He stayed right at the hospital, albeit in a different section that was defined as the 'Hospice'.

He was officially 'discharged' from normal hospital care after the hospice papers were signed and his DNR bracelet affixed. As soon as a bed on the hospice section became available he was moved from the medical floor and taken down two floors to a large private room with a dedicated hospice nursing staff and standing orders to administer only meds to ease pain and to handle all personal care needs. Family was permitted to stay 24 hours/day.

All care was handled by licensed nurses. A staff physician wrote all orders for pain relief ahead of time, eliminating the need of a nurse to say "Let me call the doctor and check". We were told that, depending on how long he was a patient of hospice, he would be carefully bathed each and every day by the nurse, who would provide any other assistance the family requested regarding his care.

100% of the cost of his time in the hospice section was covered fully by Medicare. It was the calmest and most peaceful 32 hours of his entire stay.

We were grateful for this option rather than home hospice. The event of having him at home, so ill and then passing, might always associate that memory with the home my mother still lives in.
My experience was similar...when my grandmother was in the hospital for the last time, she was able to transfer to hospice care in the same room. They didn't change her room, they simply changed the methodology with which they were treating her. Basically, they stopped stressing about overmedicating her and focused on keeping her calm and comfortable.
 
Oct 17, 2018
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#40
Same experience as well; when my mother went into a coma and there was no hope of recovery, she was transferred to hospice care in the same room.
 
Likes: AMA