Tag: Center for Medicare Advocacy

Medicare’s Efforts To Curb Backlog Of Appeals Not Sufficient, GAO Reports

By Susan Jaffe  | Kaiser Health News |  June 10, 2016

 Despite interventions by Medicare officials, the number of appeals from health care providers and patients Growing Wait Time1challenging denied claims continues to spiral, increasing the backlog of cases and delaying many decisions well beyond the timeframes set by law, according to a government study released Thursday.

The report from the Government Accountability Office, said the backlog “shows no signs of abating.” It called for the Department of Health and Human Services to improve its oversight of the process and to streamline appeals so that prior decisions are taken into account and repetitive claims are handled more efficiently.

HHS officials have acknowledged the problem. Although a judge is required to issue a decision within 90 days, the average time from hearing request to decision is slightly more than two years, Nancy Griswold, the chief administrative law judge of the Office of Medicare Hearings and Appeals, said in an interview.

Requests for hearings increased “so dramatically and so quickly over the past four or five years — during a period of time when our adjudication capacity was not able to keep up for funding reasons — we were drowning” in appeals, she said. “It is not quite as bad right now, but we are unable to keep up with [those] that are coming in the door.”  [Continued]…

Don’t Just Renew Your Medicare Plan. Shopping Around Can Save Money.

By Susan Jaffe | October 15, 2015 | Kaiser Health News in collaboration with Money magazine

Ten years after a prescription drug benefit was added to Medicare, 39 million older or disabled AmerMoney 4icans have coverage to help pay for their medicine, including most of the 17 million with private insurance policies known as Medicare Advantage, an alternative to traditional Medicare.
The annual enrollmentmedicare-shop-KHN 101515 period for these private drug and Advantage plans for 2016 starts Thursday and runs through Dec. 7.
It pays to shop around. The monthly cost is increasing an average 26 percent for UnitedHealthcare’s AARP MedicareRx Saver Plus while the First Health Value Plus plan
is dropping an average 13 percent, according to an analysis of the 10 most popular drug plans by Avalere Health, a research firm.
Some actual costs may be even more dramatic. In Albany, N.Y., the price of a Cigna-HealthSpring drug plan is going up 36 percent, according to the StateWide Senior Action Council, a New York consumer group. [More in Kaiser Health News or Money magazine]
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Congress Overwhelmingly Approves Bill Bolstering Medicare Patients’ Hospital Rights

By Susan Jaffe  | Kaiser Health News | July 29, 2015 | This KHN story also ran in nprlogo_138x46

The U.S. Senate unanimously approved legislation Monday night requiring hospitals across the nation to tell Medicare patients when they receive observation care but have not been admitted to the hospital. It’s a distinction that’s easy toKHN logo miss until patients are hit with big medical bills after a short stay.

The vote follows overwhelming approval in the U. S. House of Representatives in March. The legislation is expected to be signed into law by President Barack Obama, said its House sponsor, Texas Democratic Rep. Lloyd Doggett.observation-care photo 072915

It’s called the NOTICE Act, short for “Notice of Observation Treatment and Implication for Care Eligibility.” The law would require hospitals to provide written notification to patients 24 hours after receiving observation care, explaining that they have not been admitted to the hospital, the reasons why, and the potential financial implications.

Those implications can be dire. Observation care hurts seniors in two ways: It keeps Medicare’s more comprehensive hospitalization coverage from kicking in, and it means they may not get Medicare’s limited nursing home benefit if they need care in a facility after being in a hospital.

To qualify for Medicare’s nursing home coverage, beneficiaries must first spend three consecutive midnights as an admitted patient in a hospital, and observation days don’t count. Without that coverage, seniors could pay thousands of dollars for the nursing home care their doctor ordered, or else try to recover on their own. Observation care is a classification used when patients are not well enough to go home but not sick enough to be admitted. [Continued in Kaiser Health News]…

New Regulations Would Require Modernizing Nursing Home Care

By Susan Jaffe | July 13, 2015  | Kaiser Health News in collaboration with   nprlogo_138x46

After nearly 30 years, the Obama administration wants to modernize the rules nursing homes must follow to qualify for Medicare and Medicaid payments.

The hundreds of pages of proposed changes cover everything from meal times to use of antipsychotic drugs to staffing. Some are required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance.

“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” said Health and Human Services Secretary Sylvia M. Burwell. “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”

Officials announced the update as the White House Conference on Aging convenes Monday. The once-a-decade conclave sets the agenda for meeting the diverse needs of older Americans, including long-term care options. This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans. Medicare and Medicaid beneficiaries make up the majority of residents in the country’s more than 15,000 long-term care facilities. [MORE from Kaiser Health News and NPR]…

Officials Weigh Options To Hold Down Medicare Costs For Hospice

By Susan Jaffe  | April 23, 2015 |  Kaiser Health News and also published in

Medicare officials are considering changes in the hospice benefit to stop the federal government from paying twice for care given to dying patients. But patient advocates and hospice providers fear a new policy could make the often difficult decision to move into hospice care even tougher.hospicecare
Patients are eligible for hospice care when doctors determine they have no more than six months to live. They agree to forgo curative treatment for their terminal illness and instead receive palliative or comfort care. However, they are also still allowed Medicare coverage for health problems not related to their terminal illness, including chronic health conditions or for accidental injuries.
Medicare pays a set amount to the hospice provider for all treatment and services related to the terminal illness, including doctor’s visits, nursing home stays, hospitalization, medical equipment and drugs. If a patient needs treatment that hospice doesn’t provide because it is not related to the terminal illness — or the patient seeks care outside of hospice — Medicare pays the non-hospice providers. The problem is that sometimes Medicare pays for care outside the hospice benefit that it already paid hospice to cover.
To reduce the chances of these duplicative payments, Medicare officials have announced that they are examining whether to assume “virtually all” the care hospice patients receive should be covered under the hospice benefit….
Seniors’ advocates are worried that putting all coverage under the hospice benefit will create obstacles for patients. Instead, Medicare should go after hospice providers who are shifting costs to other providers that Medicare expects hospice to cover, said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, who urged the government to protect hospice patients’ access to non-hospice care….”If your blood sugar gets out of control, that could hasten your death,” she said. “But people shouldn’t be rushed off to die because they’ve elected the hospice benefit.”  [More from KHN] [More in USA Today]
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Medicare May Help Seniors If Advantage Plans Drop Doctors

By Susan Jaffe | December 23, 2014 Connecticut Health Investigative Team and The Hartford Courant

Next year, seniors with private Medicare Advantage insurance policies whose doctors leave their plan may be able to leave, too, under a new Medicare rule.

The Centers for Medicare & Medicaid Services (CMS), which oversee Medicare Advantage programs, will create a special three-month enrollment period in any state where insurers make network changes “considered significant based on the affect or potential to affect, current plan enrollees,” according to an update to Medicare’s Managed Care Manual.

The special enrollment period – if granted by CMS – would allow Medicare Advantage members to switch out of their plans and join traditional Medicare or another Medicare Advantage plan whose provider network includes their doctors.

…U.S. Sen. Richard Blumenthal criticized the new rule because it’s not clear what “significant” network changes would trigger a special enrollment period. Instead, he spearheaded a letter sent last Friday to Medicare chief Marilyn Tavenner, asking her to prohibit mid-year provider network changes. The letter was also signed by U.S. Sens. Sherrod Brown of Ohio and Rand Paul of Kentucky, along with U.S. Reps. Rosa DeLauro, Joe Courtney, Jim Himes, Elizabeth Esty and 13 other members of Congress.
“This blatant bait and switch should not be allowed,” they wrote. [CONTINUED in Connecticut Health Investigative Team and in The Courant ] …

Medicare To Offer Help To Some Seniors When Advantage Plans Drop Doctors

By Susan Jaffe  | December 22, 2014 |  Kaiser Health News and also published in

Starting next year, the government will offer some seniors enrolled in private Medicare Advantage insurance an opportunity to leave those plans if they lose their doctors or other health care providers.

Last year, thousands of seniors in at least 10 states were left stranded or assigned new doctors when insurers discontinued contracts with the physicians. Medicare Advantage policies cover 16 million seniors and are an alternative to the government-run Medicare program. Medicare Advantage members can only get care from a network of providers under contract to participate in their plan. They must remain in their plans for the calendar year, with some rare exceptions, but losing their doctor has not been among the permitted reasons. [More from KHN] [More in USA Today]

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Disabled Vt. Senior Wins Medicare Coverage After 2nd Lawsuit

By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | October 30, 2014

A disabled senior with serious health problems who successfully challenged Medicare for denying her home health care coverage has racked up another win against the government.

In her latest federal lawsuit filed in June, Glenda Jimmo, 78, argued Medicare should have paid for the nursing care and other skilled services she received at her home during 2007. On Wednesday, Medicare officials agreed, invalidating an April ruling that she was not entitled to coverage because her condition had stabilized and she was not improving. “I won,” said Jimmo, who is receiving rehab therapy at a Vermont nursing home and hopes to return home soon. “I’m very pleased. It makes me feel America is still in good shape.”

The settlement doesn’t mention that Jimmo was the lead plaintiff in a 2011 class-action lawsuit seeking to eliminate the so-called “improvement standard” as a criteria for Medicare coverage. In the 2012 settlement that bears her name, the government agreed that improvement was not required and allowed many Medicare beneficiaries with chronic conditions and disabilities to appeal claims that had been denied because they were unlikely to get better. [MORE from Kaiser Health News and NPR] …

Disabled Vt. Senior Who Led Class Action Suit Sues Medicare — Again

By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | October 27, 2014

A 78-year-old Vermont mother of four who helped change Medicare coverage for millions of other seniors is still fighting to persuade the government to pay for her own care.

Glenda Jimmo, who is legally blind and has a partially amputated leg due to complications from diabetes, was the lead plaintiff in a 2011 class-action lawsuit seeking to broaden Medicare’s criteria for covering physical therapy and other care delivered by skilled professionals. In 2012, the government agreed to settle the case, saying that people cannot be denied coverage solely because they have reached a plateau and are not getting better.

The landmark settlement was a victory for Medicare beneficiaries with chronic conditions and disabilities who had been frequently denied coverage under what is known as “the improvement standard” —a judgment about whether they are likely to improve if they get additional treatment. It also gave seniors a second chance to appeal for coverage if their claims had been denied because they were not improving.

Jimmo was one of the first seniors to appeal her original claim for home health care under the settlement that bears her name. But in April, the Medicare Appeals Council, the highest appeals level, upheld the denial. The judges said they agreed with the original ruling that her condition was not improving — criteria the settlement was supposed to eliminate.

After running out of options appealing to Medicare, her lawyers filed a second federal lawsuit in June to compel the government to keep its promise not to use the improvement standard as a criterion for coverage.The council’s decision makes no sense to Judith Stein, executive director of the Center for Medicare Advocacy, which filed the original class action lawsuit with Vermont Legal Aid and helped negotiate the Jimmo settlement. “People shouldn’t have to decline in order to get the care they need,” Stein said. [MORE from Kaiser Health News and NPR] …

Hospitals Required To Tell Patients Of Observation Care Status

By Susan Jaffe   |   September 30, 2014
Connecticut Health Investigative Team and The Hartford Courant

Starting Wednesday, a new state law requires Connecticut hospitals to tell all patients when they are being kept in the hospital for observation instead of being admitted and to warn them about the financial consequences.

Anyone who goes to the hospital can be placed on observation status, so that doctors can determine what’s wrong, and decide whether the patient is sick enough to be admitted or well enough to go home. Observation patients may receive diagnostic tests, medications, some treatment, and other outpatient services. Depending on their insurance, they can be charged a share of the cost. In addition to hospital bills, Medicare observation patients whose doctors order follow-up nursing home care will have to pay the nursing home themselves. Medicare covers nursing homes only after seniors are admitted to the hospital and stay through three consecutive midnights. A month in a Connecticut nursing home can cost as much as $15,000.

Medicare does not require hospitals to tell patients when they are getting observation care and what it means. And the number of Medicare observation patients is growing rapidly — 88 percent in the past six years, to 1.8 million nationally in 2012, according to the Medicare Payment Advisory Commission, an independent government agency.

…Meanwhile, more states are trying to address the situation. Connecticut becomes at least the third state in the nation, after New York and Maryland to require notification for observation status. Massachusetts, New Jersey and Pennsylvania are considering similar laws. CONTINUED in Connecticut Health Investigative Team CONTINUED in The Courant …

You’re Being Observed In The Hospital? Patients With Private Insurance Better Off Than Seniors

By Susan Jaffe   KAISER HEALTH NEWS  | September 11, 2014 | This KHN story also ran in wapo

An increasing number of seniors who spend time in the hospital are surprised to learn that they were not “admitted” patients — even though they may have stayed overnight in a hospital bed and received treatment, diagnostic tests and drugs.

Because they were not considered sick enough to require admission but also were not healthy enough to go home, they were kept for observation care, a type of outpatient service. The distinction between inpatient status and outpatient status matters: Seniors must have three consecutive days as admitted patients to qualify for Medicare coverage for follow-up nursing home care, and no amount of observation time counts for that three-day tally. That leaves some observation patients with a tough choice: Pay the nursing home bill themselves — often tens of thousands of dollars – or go home without the care their doctor prescribed and recover as best they can.

But most observation patients with private health insurance don’t face such tough choices. Private insurance policies generally pay for nursing home coverage whether a patient had been admitted or not. Here’s a primer comparing how Medicare and private insurers handle observation care. [Continued in KHN] [Continued in Washington Post]…

A Quiet ‘Sea Change’ in Medicare

By Susan Jaffe   |   March 25, 2014, 5:00  am    

Ever since Cindy Hasz opened her geriatric care management business in San Diego 13 years ago, she has been fighting a losing battle for clients unable to get Medicare coverage for physical therapy because they “plateaued” and were not  were not getting better.

“It has been standard operating procedure that patients will be discontinued from therapy services because they are not improving,” she said.

Glenda Jimmo at home in Lincoln, Vt., in 2012. (Paul O. Boisvert for The New York Times)

No more. In January, Medicare officials updated the agency’s policy manual — the rule book for everything Medicare does — to erase any notion that improvement is necessary to receive coverage for skilled care. That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.

Articles most frequently emailed by NYTimes.com readers March 25, 2014 (click to enlarge)

But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries. MORE…

As HHS Moves To End Overload Of Medicare Claims Appeals, Beneficiaries Will Get Top Priority

By Susan Jaffe  Jan. 21, 2014  KAISER HEALTH NEWS  in collaboration with 

Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog.

Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced in a memo sent last month to more than 900 appellants and health care associations that her office has a backlog of nearly 357,000 claims. In response, she said the agency has suspended acting on new requests for hearings filed by hospitals, doctors, nursing homes and other health care providers, which make up nearly 90 percent of the cases. But beneficiaries’ appeals will continue to be processed.

“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision,” said Judith Stein, executive director of the Center for Medicare Advocacy. [More from KHN] [More from Washington Post]…

Fighting ‘Observation’ Status

By Susan Jaffe   |   January 10, 2014, 2:41 pm  

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge. 

…Medicare officials have urged hospital patients to find out if they’ve been admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation.)  [Continued in The New York Times.]…

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FAQ: Hospital Observation Care Can Be Poorly Understood And Costly For Medicare Beneficiaries

By Susan Jaffe   |  September 4, 2013 |  KAISER HEALTH NEWS 

Some seniors think Medicare made a mistake. Others are just stunned when they find out that being in a hospital for days doesn’t always mean they were actually admitted.observation-care KHN Sept 2013

Instead, they received observation care, considered by Medicare to be an outpatient service. Yet, a recent government investigation found that observation patients often have the same health problems as those who are admitted. But the observation designation means they can have higher out-of-pocket expenses and fewer Medicare benefits. Here are some common questions and answers about observation care and the coverage gap that can result. [Continued here]

 

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HHS Inspector General Scrutinizes Medicare Rule For Observation Care

By Susan Jaffe | July 30, 2013  |  Kaiser Health News  in collaboration with washingtonpost logo
Medicare patients’; chances of being admitted to the hospital or kept for observation depend on what hospital they go to — even when their symptoms are the same, notes a federal watchdog agency in a report to be released today, which also urges Medicare officials to count those observation visits toward the three-inpatient-day minimum required for nursing home coverage.
The investigation, conducted by the Department of Health and Human Services Inspector General, was based on 2012 Medicare hospital charges. Its findings, which underscore several years of complaints that the distinction between an inpatient and observation stay isn’t always clear, come just days before the Centers for Medicare and Medicaid Services (CMS) is expected to issue final regulations intended to address the problem. [Continued in Washington Post and in KHN]

 

FAQ: Medicare Beneficiaries May See Increased Access To Physical Therapy Or Some Other Services

By Susan Jaffe | June 25, 2013 | Kaiser Health News  in collaboration with

For years, seniors in Medicare have been told that if they don’t improve when getting physical therapy or other skilled care, that care won’t be paid for. No progress, no Medicare coverage — unless the problem got worse, in which case the treatment could resume.
This frustrating Catch-22 spurred a class-action lawsuit against Health and Human Services Secretary Kathleen Sebelius. In January, a federal judge approved a settlement in which the government agreed that this “improvement standard” is not necessary to receive coverage.

“This will help a lot of older or disabled people who clearly need the skilled care and aren’t getting it because they will not get better,” said Margaret Murphy, associate director of the Center for Medicare Advocacy, which helped bring the lawsuit. “The settlement recognizes that Medicare will pay for care to maintain their condition and prevent backsliding.”

Yet providers may not know about the settlement yet and may still be telling patients, incorrectly, that Medicare won’t cover treatment if there’s no improvement. MORE

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Advocates Head To Court To Overturn Medicare Rules For Observation Care

By Susan Jaffe   |   May 3, 2013 |  KAISER HEALTH NEWS produced in collaboration with USA Today logo 2012

Lois Frarie and her husband Wayne live in a Park Lane senior community home in Monterey, Calif. (Photo by Jay Dunn/The Salinas Californian for USA Today.)

After Lois Frarie, a 93-year-old retired teacher from Monterey, Calif., spent four days at a local hospital while being treated for a broken elbow and pelvis, she went to a nearby nursing home to build up her strength.

But her family was stunned to find out that they would have to pay thousands of dollars up front since two of the days she spent in the hospital were considered “observation care.” She wasn’t an admitted patient for at least three consecutive days and therefore she didn’t qualify under federal law for Medicare’s nursing home coverage.

Advocates for seniors say the distinction is not fair to patients.

They are taking their argument to federal court in Hartford, Conn., Friday for the first hearing on a lawsuit seeking to have Medicare eliminate the observation label. Government lawyers argue in court filings that Medicare considers observation care an outpatient service and if elderly patients think they should have been admitted to the hospital, they should file an appeal. [Continued in Kaiser Health News, and in USA Today PDF or online.]

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Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

By Susan Jaffe   |   May 3, 2013    |     KAISER HEALTH NEWS  in collaboration with washingtonpost logo

Medicare officials have proposed changes in hospital admission rules that they say will curb the rising number of beneficiaries who are placed in observation care but are not admitted, making them ineligible for nursing home coverage.

“This trend concerns us because of the potential financial impact on Medicare beneficiaries,” officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.

…The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea. MORE

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$18 For A Baby Aspirin? Hospitals Hike Costs For Everyday Drugs For Some Patients

By Susan Jaffe | April 30, 2012 |  KAISER HEALTH NEWS produced in collaboration with usat 4sidebar

For the price Diane Zachor, 66, was charged for one pill to control high pressure during her 18 hour stay at St. Luke’s Hospital In Duluth, MinZachorn., she could have bought a three-week supply.  In South Florida, Pearl Beras, 85, of Boca Raton, Fla., said her hospital charged $71 for one blood pressure pill for which her neighborhood pharmacy charges 16 cents. Several other Medicare patients in Missouri were billed $18 for a single baby aspirin, said Ruth Dockins, a senior advocate at the Southeast Missouri Area Agency on Aging.

It’s no mistake: When Medicare patients are in hospitals for observation, they can be charged any amount for routine drugs to treat chronic conditions such as diabetes, high blood pressure or high cholesterol.  Medicare doesn’t cover these type of medications and doesn’t require hospitals to tell patients when they are in observation status or that they will be responsible for paying any non-Medicare-covered services.   

“I just couldn’t believe some of these prices they charge,” said Zachor (left). “It’s just atrocious.”  [More from USA Today or from Kaiser Health News]