Monday, March 14, 2011

Medicare Beneficiary Advocates

Resolving Medicare Covered Services Complaints
Question:  Connie, my father's doctor prescribed oxygen late in the day Thursday. Home Health called Friday after 5 p.m. to say [the nurse] had worked late to coordinate with the contract provider of the oxygen. HOWEVER, they cannot bring the equipment until Monday, as the battery on the equipment would not last over the weekend and Medicare requires an overnight test to determine that he needs oxygen. It doesn't seem right that my father must wait 5 days (Th-Fri-Sat-Sun-Mon) before getting the oxygen needed. Where do we turn for an advocate?
Answer: You, informed and empowered, are your best advocate. If that fails to resolve an issue, there is The Medicare Ombudsman program through CMS (the Center for Medicare and Medicaid Services). They receive complaints and do take action. It isn’t necessarily punitive. They have a “reeducation” process when mistakes are made from lack of knowledge or understanding. Negligence and fraud are another matter and they do handle this also. There are also Ombudsmen affiliated with local/regional Area Agencies on Aging who advocate for Medicare beneficiaries. These area agencies focus primarily on Assisted Living and Nursing Home facilities. I’m pretty sure they also step in with Home Health complaints. If your dad is covered by an Advantage plan, you must contact the Advantage plan. They have full caseloads so try the informed and empowered route first!

So…How to be informed and empowered. The answers are out there, you just have to know where to look and I’m happy to point you in that direction. Here are 2 links so you understand Medicare’s process for providing Oxygen.

You’ll see there are criteria for justifying oxygen (or any other service). I’m guessing your doctor took care of documenting the criteria as being met.

Next, call Medicare 1-800-633-4227, explain what has happened. You’ll need your dad on the phone to give his permission for you to speak to them on his behalf. If Medicare feels the situation is not right, they will help initiate the complaint process. At this point you may want to request a different home health agency and/or different oxygen provider if you aren’t feeling confident in this one. It’s OK for you to do this.

It does not seem reasonable, based on the information you provided, for it to take 5 days. Your concern is justified.