AMBULANCE BILL TAKES SENIOR FOR YEARLONG RIDE

Original Story: Chicago Tribune

Just days after Bernita Klokner's family moved her from Florida back to the Midwest last May, the 97-year-old fell and broke her hip.

After the ensuing surgery, Klokner was moved from a hospital in Milwaukee to a nearby rehabilitation center.

The ambulance company charged her $585.70 for the ride, but neither she nor her family was particularly worried. They submitted the claim to WellCare, the health insurance company administering her Medicare plan.

They had no idea there would be any trouble until they got a denial letter in July.

The letter informed Klokner that WellCare would not pay for the ride because she had not submitted proof that the ambulance company had gotten prior authorization.

Klokner's daughter, Sharon Reich, of Grayslake, was stunned. Reich, a registered nurse, said she has filled out similar forms many times for her patients.

She promptly requested, and received, the proper paperwork from her mother's doctor and, in early September, filed an appeal.

Ten days later, WellCare wrote back saying it would not consider the appeal because Reich wasn't authorized to represent her mother.

In late September, Reich sent paperwork proving she legally represents her mother. WellCare again dismissed the appeal in November, stating it had not gotten Reich's documents.

Reich said she called WellCare in December, and a representative told her she had found Reich's paperwork. The representative said the insurance company would reconsider paying the $585.70.

Months passed and Reich heard nothing. When she called, she was promised a return call within days. No one called back, Reich said.

By May, Reich still hadn't heard whether WellCare would pay the ambulance bill, and she was beginning to worry all hope was lost. She tried calling the insurance company again, but phone lines were jammed, she said.

"I can't get through on the 800 number," she said. "I call and you get these prompts. I go through the prompts. You get a recording. The phone rings 53 times, and then it hangs up."

Undaunted, Reich began calling WellCare's corporate headquarters. She had two brief conversations, then was disconnected both times, she said.

"Every time I call, there's a different reason why they're not paying it," she said. "I don't know what to do."

Tired of fighting a seemingly unwinnable battle with WellCare, Reich emailed "What's Your Problem?" in mid-May.

She said the ambulance company has been patient, but it has been more than a year.

"It's expensive," she said of the $585.70. "In short, this claim should be paid."

The Problem Solver called WellCare and explained the situation.

On Wednesday, WellCare spokeswoman Crystal Warwell Walker emailed with good news.

Walker said that although emergency health services do not require prior authorization, WellCare does require such authorization for some nonemergency services, such as ambulance transportation.

"When a pre-authorization is not obtained before a service is delivered, a claim may be denied," Walker wrote.

Members can appeal by providing proof of authorization, she said. Also, representatives wishing to address a matter on behalf of a member must provide proper paperwork, Walker said.

"Any time the processes and associated deadlines are not followed, a claim cannot be approved per the protocols," Walker said.

But after examining Klokner's case, the insurance company decided to overturn its initial decision.

"WellCare understands that there can be cases where protocols are followed, but the outcomes are not in line with a provider's intent and the member's health care needs," Walker said. "In this specific case, the matter has been reviewed and WellCare will pay the claim due to the unique circumstances."

Reich was shocked. She said her mother, now 98, could never have fought WellCare on her own.

"I don't know if an older person who qualifies for Medicare like my mother can deal with these people," Reich said. "They would just give up."

Requirements of Health Care Reform Affirmed

story first appeared in Los Angeles Times

The Obama administration reaffirmed key requirements of the new healthcare law Tuesday, setting out how insurance companies will cover nearly all Americans, even if they are already ill, and provide plans with minimum benefits.

Consumer advocates, insurers and business groups were looking for signs the administration might try to modify some of the law's requirements as the federal government races to implement the legislation by the end of next year.

But the proposed rules issued Tuesday hew closely to the Affordable Care Act that President Obama signed in 2010. At the same time, administration officials restated their commitment to move rapidly ahead, despite continued resistance from some Republican governors.

Health and Human Services Secretary Kathleen Sebelius said  this means that beginning in October next year, families and small-business owners everywhere will be able to shop for affordable, quality health coverage and entrepreneurs won't have to give up their chance at affordable health coverage to start a new business.

Under the law, Americans who are not covered through work will be able to comparison shop for health insurance in online markets, also known as exchanges, designed to mimic the shopping experience of popular travel sites.

These exchanges will be run by state governments, except in states that elect to leave the job to the federal government or to partner with Washington.

More than 15 states, mostly with GOP governors, have said they will not operate an exchange. Some governors have complained the federal government has put too many requirements on the exchanges.

In state and federally run exchanges, insurance companies will be prohibited from denying coverage to sick Americans. Insurers will no longer be able to charge more from women or customers with medical conditions.

And for the first time, insurers will have to cover 10 basic benefits, including hospitalizations, emergency care, newborn and maternity care, and prescription drugs.

The Obama administration has allowed each state to detail this set of benefits, allowing for some variations of drugs that might be covered, for example.

That worries many consumer advocates who would like to see a national standard for health insurance. Carl Schmid, deputy executive director of the AIDS Institute fears that leaving the decision up to the states of which drugs insurance plans must cover, many patients, particularly those with complex medical conditions, may not have the coverage they need.

But several leading consumer groups, including AARP, which represents older residents, and the American Cancer Society's Cancer Action Network, applauded the administration for retaining key protections in the law, including a requirement that insurers charge elderly consumers no more than three times as much as they charge young customers.

Insurers had pushed for more leeway to vary rates based on age, arguing that this was necessary to keep premiums affordable for younger, healthier customers.

Gary Cohen, who oversees insurance regulations at the Department of Health and Human Services, said the administration did not believe this was necessary to attract younger consumers, who will have access to a lower-priced health plan to cover catastrophic illness and also may qualify for new subsidies to offset their premiums.

The administration adjusted several rules to accommodate industry concerns, including allowing insurance companies to institute higher deductibles in plans they sell to small businesses and setting enrollment periods to prevent consumers from signing up for insurance only when they get sick.

The proposed new rules drew cautious praise from several leading industry representatives. Karen Ignagni, head of America's Health Insurance Plans, reiterated concerns that requirements still may force consumers to purchase coverage that is more costly than they have today.

Michigan Woman Dies From Flesh-Eating Bacteria

Story first reported from USA Today

FARMINGTON HILLS, Mich. -- Twelve days after doctors told a woman that she was finally clear of a life-threatening flesh-eating bacteria infection, she took a turn for the worse and died.

Crystal Spencer, 33, had spent a month in and out of three hospitals. Her husband had been visiting a rehabilitation hospital Sunday where she was about to be transferred when the hospital called and told him to return immediately.

A team of eight doctors worked for more than an hour to resuscitate his wife, amid alarms indicating she was near death three times. She died at 3:36 p.m. Sunday.

The family is raising money to conduct an autopsy to find out as much as they can about what happened. Results could take several weeks.

Until about a week ago when they learned that their application for Medicaid had been approved, the Spencers had limited health insurance. Now Jeff Spencer said he has thousands of dollars in medical debt from care not covered by insurance.

Crystal Spencer was a high school dropout and had been poor and underinsured or uninsured most of her life. She had adult-onset diabetes and weighed more than 300 pounds all of her adult life, factors that put her at higher risk of contracting the flesh-eating bacteria.

Her death from necrotizing fasciitis has drawn national attention to a rare disease many had never heard of and others knew only by its scary name: the flesh-eating bacteria.

Nationwide, the U.S. Centers for Disease Control and Prevention has reported 500 to 1,500 cases a year; 1 in 5 people dies from it. Many others have fingers, toes or limbs amputated because the bacteria eats away at underlying layers of tissue.

Many cases are misdiagnosed or found late, according to the National Necrotizing Fasciitis Foundation, a nonprofit founded by two women who survived the infection.

The foundation hopes to raise awareness about a problem that needs more education and hospital early intervention programs so symptoms can be caught and treated with antibiotics or the removal of dead skin and infected tissue, a procedure called debridement. Others need surgery, including extensive skin grafts.

Too often, patients get the wrong treatment because the infection is misdiagnosed, according to the foundation

Jeff Spencer said doctors at Huron Valley-Sinai in Commerce Township, Mich., originally had told him his wife had a urinary tract infection. At Botsford Hospital here, where she first sought care June 23 for what she thought was a boil on her upper right thigh, an emergency department physician lanced the protruding tissue and sent her home with a Motrin prescription, said Theresa Corwin of Farmington Hills, a close friend.

She and Spencer blame Botsford for not running blood tests to see whether white blood cell counts were elevated, a sign of infection.

They also wonder why a doctor there called the infected area on her leg an "abscess" -- an accumulation of pus and tissue triggered by an infection -- but gave them no warning that Crystal Spencer might be contagious. Corwin, who said she is certified in CPR and first aid, was given the job of cleaning the wound and changing the dressings four to five times a day when her friend got home.

On Monday, Botsford spokeswoman Margo Gorchow said it was unlikely that Crystal Spencer contracted necrotizing facitiitis there because the infection typically is not acquired in a hospital, and the woman had none of its symptoms when she came to the emergency department.

A spokeswoman for Huron Valley-Sinai declined comment both Monday and Tuesday, citing patient privacy laws.

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Charity Aid System Corrupting Hospital Practices

First appeared in NY Times

For most of her life, Hope Rubel was a healthy woman with good medical insurance, an unblemished credit history and a solid career in graphic design. But on the day an ambulance rushed her to a Manhattan hospital emergency room shortly after her 48th birthday, she was jobless, uninsured and having a stroke.

Ms. Rubel’s medical problem was rare, a result of a benign tumor on her adrenal gland, but the financial consequences were not unusual. She depleted her savings to pay $17,000 for surgery to remove the tumor, and then watched, “emotionally paralyzed,” she said, as $88,000 in additional hospital bills poured in. Eventually the hospital sued her for the money. An Omaha Hospital Lawyer is interested in these cases.

Yet that year the hospital, NewYork-Presbyterian/Weill Cornell, had already collected $50.2 million from the state’s so-called Indigent Care Pool to help care for people like Ms. Rubel who have no insurance and cannot pay their bills.

New York’s charity care system, partly financed by an 8.95 percent surcharge on hospital bills, is one of the most complicated in the nation, but many states have wrestled with aggressive debt collection by hospitals in recent years. Like New York, several passed laws curbing hospitals’ pursuit of unpaid bills, including Illinois, California and Minnesota.

But a new study of New York hospitals’ practices and state records finds that most medical centers are violating the rules without consequences, even as the state government ignores glaring problems in the hospitals’ own reports.  An Oklahoma City Hospital Malpractice Lawyer is interested in defending the health care system in these situations.

“The entire system is corrupted, and it isn’t working for patients,” said Elisabeth R. Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit antipoverty group, which is releasing the two-year study on Monday.

The state’s Department of Health acknowledges systemic problems, including the need for better reporting and enforcement, a spokesman, Michael Moran, said. A group of patient advocates and hospital administrators is being convened to develop a better system, he said, and the department is engaged in “a comprehensive data integrity project that will include the retention of an outside auditor.”

The study found that some hospitals did not provide financial aid applications at all, and that many made impermissible demands for irrelevant documents or failed to supply key information, like eligibility rules for big discounts required by state law in 2007. Data reported to the state was obviously faulty, it found.

Yet even hospitals that reported they had spent nothing on financial aid, or had filed hundreds of liens against patients’ homes, were allowed to collect without questions from the charity care pool, which distributes more than $1 billion a year.

Hospitals are not legally barred from seeking judgments or liens, but must first offer an aid application, help the patient complete it, and wait while it is pending. Instead, many hospitals turn to collection agencies, and sue when that fails. The unpaid bills — typically reflecting much higher rates than what insurers pay — are then treated as the equivalent of charity care.

Change is now urgent, health care experts agree, because the state pool stands to lose hundreds of millions of federal dollars in 2014, when provisions of the health care overhaul will no longer treat so-called bad debt, based on uncollected bills, as if it were charity care.

“There’s a law in place, and obviously it should be complied with,” said David Rich, an executive with the Greater New York Hospital Association, a trade group. But, he added, “hospitals are providing a lot of charity care at a loss.”

He said hospitals were improving their compliance with the law, which requires aid to patients with income up to 300 percent of the poverty line, or up to $33,000 for a single person. But, often stymied by patients who fail to complete applications for aid, he said, many hospitals have moved to simply deeming some patients eligible without an application, using what he called “a soft credit check” at registration to gauge income and assets.

Myrna Manners, a spokeswoman for NewYork-Presbyterian Hospital, said that it would be inappropriate to discuss specific cases, but that the hospital “proactively helps patients at every step” of the financial aid process. It approved 25,861 applications in 2010, the most recent annual data.

“Where there has been a determination that there is an ability to pay, we still go to all lengths to ensure that we resolve the matter before it becomes a legal action,” she said.

Court records abound in judgments against patients who say they had little or no chance to apply for help. A couple fighting foreclosure in Elmont, Nassau County, has a $41,000 default judgment from NYU Langone Medical Center for emergency surgery on their disabled adult son in 2007, when their insurance unexpectedly dropped him. He was eventually approved for Medicaid, but it would not pay for the surgery retroactively.

The mother, Myrlene Stimphil, 55, a nurse at a city hospital, said she had sought a reduced payment plan from NYU Langone, but was told only that the hospital would get back to her. Instead, she said, collectors were calling her son, now 24, who suffered brain damage at his premature birth.

“We don’t want to be a burden,” she said, as her husband, Antenor Francois, 56, a former cabdriver, looked through old bills. One announced, “Welcome to Portfolio Recovery Associates!” and added that the collection agency “purchased your account from NYU Hospitals Center.”

Lisa Greiner, a spokeswoman for the hospital, which collected $10.7 million from the charity care pool in 2010, said she could not comment on the case under privacy laws. But the hospital no longer uses that collection agency, and under new leadership in the last three years, its reported financial aid approvals soared to 36,000 in 2010, from 256 in 2008.

Christopher Ward, 49, living in his father’s house in White Plains on a $200-a-week disability payment from a workplace spinal injury, recalled stopping at an A.T.M. — “just to have something in my pocket to buy food” — and discovering that his accounts, totaling less than $4,000, had been seized.

“I tore my hair out for a long time not understanding why all this was happening to me,” Mr. Ward said, admitting to memory lapses.

Court records show that NewYork-Presbyterian obtained a $102,636 judgment against him in 2007, including 9 percent interest back to 2004, when, uninsured, he underwent emergency surgery for a brain aneurysm. Now his ailing, widowed father, 75, a teacher at Mercy College, worries that anything he leaves for Christopher could be seized.

State hospitals seem to be especially aggressive collectors. State University of New York Downstate Medical Center, in Brooklyn, secures hundreds of judgments annually through the attorney general’s office, which says such suits protect the state’s interest in case a former patient comes into money. A Clarksdale Hospital Lawyer is watching these cases closely.

One picked at random: a $12,000 judgment in 2008 against Cherrilyn McFarlane, a single mother on public assistance, for one day’s care for her newborn five years ago, when her Medicaid coverage had briefly lapsed. Ms. McFarlane said the judgment could hurt her plans to seek a student loan for nursing school. “I want to get it cleared,” she said.

To Hope Rubel, the greatest fear was that the suit itself would deter employers from hiring her and leave her destitute, she wrote the judge. Finally, she said, a law clerk directed her to the hospital’s financial aid department. It said more documents were needed to decide her eligibility.

“I had given them everything,” she said. In despair after a year of courthouse meetings, she said, she offered $100 a month, and at the court’s urging, the hospital’s lawyers accepted. “I’ll be paying for the rest of my life,” she said.