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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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ProPublica has an article out today on RN who was billed $880,000 for her 3 mo early preemie & it’s the hospital group she works for!!!

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.
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newbiewife Nov 5, 2019
Amen to trying to get a more rational healthcare system in the U.S.! We've never had problems with getting care up until now, as every provider and every facility to which we've been referred is in our plan's network, which appears to be quire extensive. In our case, the problem is getting the appropriate level of care. We just got the denial letter (dated October 29th) on November 4th. It said the requirements for skilled nursng facility was needing skilled nursing or rehab every day that can only be required in an inpatient setting. We, and the sending and receiving facilities, think my husband easily meets the criteria for short-term inpt. rehab, and we're pursuing an appeal.
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Have the hospital recheck the code numbers they used. You won't believe how often a refusal is caused by the wrong code numbers.

I learned this the hard way - now I make them recheck anytime a charge is refused.
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Reply to RayLinStephens
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Herein lies the problem with the Medicare Advantage plans. Little to no cost to you, but when you need medical attention you find out how little is actually covered and the hoops you need to go through to get that coverage. Could be the hospital billing dept. used the wrong code. Did your husband sign an ABN (advanced beneficiary notification)? If so, was it explained correctly? Is the hospital/rehab in the network? Did he need to get a referral for the surgeon/hospitalization/rehab? Was he in the hospital for a minimum of three days?

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.
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igloo572 Nov 5, 2019
Abby for newbies making selections Original/ Traditional MediCARE for 2020 on supplemental or “gap” plans, there’s no more Plan F!
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.
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Well, my mother has this super crappy new Medicare PPO plan thru Blue Cross that works a lot differently than standard Medicare, and may be similar to what you're dealing with. When she needed rehab after a bout in the hospital with pneumonia, a few rehabs wouldn't take her.....said they were "full". To make a very long story short, I later found out those rehabs weren't full at all......they just wouldn't take any more Medicare PPO plan patients! Apparently, there are only a certain number of beds allotted towards each insurance plan. When that number is reached, everyone else presenting with that type of insurance is DENIED. Hopefully my gibberish makes sense.

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?
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igloo572 Nov 5, 2019
My understanding is Medicare PPO tend do post hospitalization care by “bundling”. So whatever the ICD-10 codes are for in the discharge report for them factor in for the post care they get but it’s paid NOT to each providers time but by a bundling of the overall $ amount that will be paid. So say it’s $475 a day but that $475 has to cover daily room&board, medication management, PT, OT, SW and the facility has to ferret out to pay all involved. If the facility has staff that are not true employees but independent contractors (which PT & OT & ST can be as they hold their own licensing), or some services not considered part of rehab (medication management), it’s a mess to pay. Facility might can do 3 -5 of these beds out of 20 beds. But more than that will mean very unhappy employees & negative bottom line for rehab sector. Families visiting see that their elder isn’t going off to PT twice a day like others are and complaining to management.

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.
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Everyone on Medicare makes their own choices of what doctor to see. Medicare is a very generous payor. The days of fee-for-service are gone and never going to come back unless you can afford to pay out of pocket. Ask anyone on Medicare whether they want to give it up and you will get a resounding "hell no!" The amount of misinformation about Medicare is staggering.
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Just read in the Sunday New York Times under a title of most frequently asked questions about Medicare that many advantage plans deny care and that only 1% actually will protest that denial with an appeal, that often when they do the denial is withdrawn and the care is given. Access this article if you are able. This apparently is VERY COMMON with medicare advantage programs. Article is named Six Top Questions about Medicare by Mark Miller andis in the Business Section of the November 3 New York Times under "retiring". I know you can get this on google. Good luck.
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Abby2018 Nov 4, 2019
Alva.....My husband had the unfortunate experience of dealing with an appeal and had all the paperwork in order...including the oncologist explaining why the PET scan was necessary. It took weeks for me to get all the necessary documentation and forward it to CMS before the deadline (the hospital took three months to bill....so we were under a very small window). We thought for sure this would be resolved. Nope. Now on to investigating hospital billing codes, reasons for denial on their part, etc. Numerous calls to Medicare (you can't speak to anyone at CMS who are in charge of appeals) and finally someone took the time to look back at the claim. I was told a proper ABN was never filled out (a form stating Medicare would most likely NOT cover the test and advising patient of the cost and the reason it would likely be denied). Hospital still insisted that we pay.....I contacted Medicare multiple times again (going down the chain and up the ladder) and finally they threatened to file a grievance against the hospital for violation of contractural agreement. Weeks later my husbands $10K balance went down to zero.

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.
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I am new to medicare (as of 1 dec) finally....ive heard too many “advantage” nightmares. I went straight medicare with plan f and part d. My mom has the original supplement plan and never pays a penny for anything except copays for her meds....i used to work in the medical field and at one point did insurance billing....the crap plans that are so well advertised, basically shoved down our throats, are no advantage to a patient, as someone on the forum mentioned not too long ago...
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texasrdr22 Nov 12, 2019
Interesting. I have had an Advantage Plan since I signed up for Medicare (5 years ago). I am healthy and have had no trouble whatsoever getting my plan to cover whatever I need. I have a PPO so don't have to get a referral. I have to stay within their network of doctors, but all my docs were in that network anyway.

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.
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Happy update! Our appeal of the denial was successful, so Aetna Medicare Advantage (ppo plan) will pay retroactive to admission to the facility.

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.
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Maple3044 Nov 7, 2019
Ssorry to hear of your problems. My mother had an advantage plan ( rhymes with Hell Med) who denied her coverage at a SNF 5 days after she had a major stroke. They arbitrarily transferred her to this facility with no input from us. It was extremely inconvenient for us to get to it. Their excuse was that she was making no progress with therapy. We fought them stating that she had had 1 day of evaluation and 1 actual day of therapy. Hell Med did capitulate and authorized 30 days of therapy. My mother never recovered from her stroke but seemed to be content in the SNF until she passed 4 years later.
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First off, keep appealing. I used to write appeals for a Blue Cross HMO before changing career path.

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.
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Wow. I came SO close to changing over to an Advantage policy instead of the supliment one I have now. I pay a very small co-pay at the beginning of the year and from that point on no deductions. And you guys are right, even my doctor's office is trying to get us to with advantage....
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bevwill88 Nov 7, 2019
Wwhich plan do you have; it sounds promising
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