Denied rehab stay by Medicare advantage insurance, post hip replacement surgery. Others have this experience? What did you do?

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.

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.

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.

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?

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.

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.

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...

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.

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.

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....