Denied rehab stay by Medicare advantage insurance, post hip replacement surgery. Others have this experience? What did you do?
My husband recently had to have unplanned hip replacement after fracturing his upper femur due to a fall. Hospital referred him to a facility for inpt rehab and the pre certification was denied by our Medicare advantage insurance company. Hospital and receiving facilty were both astounded at the denial, as hubby has other complicating factors potentially impacting rehab, so it's not a simple case. We are of course appealing the denial. In the meantime we did manage to get him transferred to a SNF (skilled nursing facility) where he's making great progress. We are "self pay", but fortunate to have long term care insurance insurance that is willing to pay for the stay though not for the therapy services. If successful in our appeal, the Medicare advantage plan will pay retroactively to admission date. We are more fortunate than others in having the LTC insurance, but we hate to have to use it when Medicare should be paying. I suspect if we had traditional Medicare they would not have denied the rehab stay.
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Its the structure of “Advantage” plans that are the inherent problems.
The whole premise of Advantage is to limit you to a narrow network with an even narrower group of providers. So if the care you need doesn’t fall within basically a subset of a set, just too bad. You pay out of network or you get wage garnishment or go bankrupt or you impoverish yourself to be a dual on Medicaid/Medicare. What’s especially galling is that CMS underwrites a good bit of Advantage Plans. They siphon off $ from original MediCARE for Advantage. All done under the illusion of creating a more “choices for consumers” via underwriting insurers who trot out Advantage plans; and taking $ away from Original MediCARE. What a steaming load.
Single Payor needs to happen in the US. Whether it’s MediCARE for all or the Kaiser model (Alva oh lucky you!) of HMO systems.
I learned this the hard way - now I make them recheck anytime a charge is refused.
The groundwork is relentless....to protect yourself in the future my advice is to check out the supplemental F plan. You can enroll now at a cost of about $235 per month. Covers mostly everything and no need for referrals.....and you are covered in all 50 states. Plus all major insurance carriers have the exact same plan. We learned the hard way....I am not a solicitor for the insurance industry.....just a graduate from the school of hard knocks.
Good luck to you and I hope this is just a hiccup that will resolve itself and you will receive full reimbursement. Getting proper medical treatment should not be this hard......especially when you are under enough stress to begin with.
You who have your existing F can roll yours over but no new ones.
oh so not happy as going Original with an F was just going to be what we did when hubs retired. We’re still on his employers “Cadillac” plan (& @ $570 biweekly for family coverage & his insurance it should be a Ferrari) but now I need to research just wtf to do upon retirement since no F.
I think the Plan C is going this route for new 2020 enrollment too.
So I wound up putting my mother in a rehab unfit for a dog because Medicare PPO plan sucks, basically. Took me 5 days to get her out of there and into a good place and that's how I found out about all of this Medicare nonsense.
I wonder if your plan was rejecting the FACILITY and not the need for rehab?
rehab coverage seems to be glossed over in all the plans I’ve looked at. I wish I knew which plans have in detail what’s covered in rehab.
We had straight Medicare ( with a supplement) and after months of calling and questioning, I finally found that one person who was willing to care enough to look back at the records and was astute enough to pinpoint the error. My advice to everyone.....due diligence does pay off, but you need to be your own advocate.
I found the cost of the MediGap (supplement) policies to be quite high! Plus you have to pay for a Part D drug plan and still pay the monthly Social Security part (that is automatically deducted). This adds up! My Advantage Plan includes part D. My mother has a different carrier for her Advantage Plan and it is amazing all the things it covers! Neither of us have had problems other than the denial of inpatient rehab which I appealed and it was granted.
To address a few of the questions raised by helpful posters: (1) This was not a planned or elective hip replacement surgery. It was necessitated by a fall that resulted in broken femur, near the head. Surgeon said it was a displaced fracture. Not a total hip replacement, "just" the head of the femur. (2) My husband was admitted to the hospital from emergency room and had to wait a day before surgery because he was on a blood thinner. He was in the hospital over the 3 days required by Medicare to be eligible for rehab. In fact, he was in there several extra days because of the Aetna denial. He has other complicating medical factors that already affect his balance and walking, so we were sure he ought to be elgible for rehab. stay medically as well. (3) We had no choice in having this advantage plan as my husband's employer has contracted to put all their retirees on it. The employer heavily subsidizes the employee's monthly premium, and dependents have a very reasonable monthly premium. Between two of us, we are paying only slighty more than half of what our brother in law pays for just himself on a Medicare supplement plan (United Healthcare). Annual deductible is $300 each, and there's a decent cap on annual out of pocket payments. Prescription (Part D) benefits are included.
I've learned a lot in reading the responses, which I think may be helpful for others as well. Thanks all.
Second-without knowing if he satisfied Medicare’s three day hospital inpatient requirement, we can’t know if he qualified for rehab facility.
Third-Medicare is moving toward outpatient joint replacements, same day discharge, or next day. They are doing this partly to prevent joint replacement patients from qualifying for rehab care post-hospital discharge. Virtually nobody with hip surgery qualifies for rehab now. Just because the model patient without comorbidities May do well with outpatient joint surgery, we all are now expected to recover just as quickly.
Fourth-As others have said, if a person is on a Medicare Advantage Plan, if one can get through underwriting, and if the premiums are affordable, Original Medicare with a supplement, Plan G, is best option, for getting needed care, with all the Advantage Plan restrictions.
You say Medicare PPO, not HMO, correct? You will probably find, as your husband ages, most seniors tend to get sicker and need more care, not less. Insurance companies are in the business of making profit, whether HMO or PPO, and its a powerful incentive to deny as many services as they can get away with. We said good riddance to the south FL Medicare Advantage Plan HMO Humana, when we moved to another state. Both back on original Medicare. We don’t have all the games with insurer denying care now. We are receiving proper medical care, and the screening tests for our various medical needs, plus the accepted medical treatments we weren’t receiving on the Advantage Plan. Strongly urge changing to Original Medicare if you can.