While many children engage in games of playing dead for a moment or two, few adults have the bizarre experience of being marked as deceased while they are still very much amongst the living. For an elder, this can pose a whole host of problems, particularly when it is a government entity linked to their health care benefits that got this important fact wrong.
This scenario happened to one New York woman, Mrs. B, in the fall of 2013 before she had a major stroke and moved to California to be under her sister’s care. Medicare began denying all her claims because, unbeknownst to Mrs. B, in Medicare’s system, her record indicated she was deceased. Her primary doctor stopped receiving payments (as Medicare denied all his claims), and he refused to provide continued care, let alone refer her to other doctors, as he presumed they also would not get paid. Meanwhile, the mistake in Mrs. B’s Medicare record was transmitted to her Medi-Cal record, and Medi-Cal stopped paying for her nursing home care. Her sister, Mrs. B’s primary caregiver, became distraught and reached out to as many government and insurance entities as she could over a 4-month period, desperately trying to resolve this mistake and get Mrs. B’s care reinstated.
It was not until Mrs. B’s sister found the Health Insurance Counseling and Advocacy Program (HICAP) and brought this case to Ruth Atkin, HICAP Program Manager for Contra Costa County, that her situation began to be resolved just a few weeks later. Now Mrs. B is once again receiving all her Medi-Cal and Medicare benefits. This article describes what happened and demonstrates the power of the “A” in “HICAP,” the advocacy often necessary to resolve even a seemingly simple mistake. While we encourage people to be their own advocate, sometimes people need someone who knows the system and has connections to make corrections. This case highlights the power and effective advocacy work of HICAP staff and volunteers statewide who routinely go the extra mile to make sure our seniors are taken care of and receive the quality health care they require.
What went wrong?
Somehow the Medicare Part A contractor in New York State mistakenly put a date of death of 10/19/13 in Mrs. B’s file. And that was BEFORE she had a stroke later that month. How and why that happened is still a mystery. After Mrs. B’s stroke, she was moved to California via air ambulance to be under her sister’s care. This is when the chaos described above all started. After 4 months of trying to rectify this problem on her own, Mrs. B’s sister and primary care giver made a call to HICAP for help.
Ruth Atkin and the other HICAP Program Managers, staff and volunteers statewide are dedicated advocates, often doing whatever is necessary to get their clients’ coverage and benefits back on track.
In this case, several entities were involved (the client’s doctors, Medicare, Social Security, Medi-Cal, the nursing home, Medicare Part A contractor, etc). Ruth focused in on Medicare and Social Security, knowing that if the client’s info was corrected in both these government systems, the rest would be resolved.
In the first call to the Medicare call center, Ruth learned that the mistake first showed up in Mrs. B’s record with the New York’s Medicare Part A contractor. The Medicare customer service representative initiated the request for that Part A contractor to remove the death date and told Ruth to call back in 1 week to go over the numerous denied claims. Ruth called back, and for 70 minutes they went through all 28 denied claims. Just as they finished, the system crashed and all the data was lost! Instead of sitting on the phone for another 70 minutes, Ruth generously offered to contact the providers herself and ask them to rebill Medicare for their services.
Next Ruth knew she needed to rectify things with Social Security. This wasn’t so easy as she found that Social Security is used to one-way communication. They can easily share and send info to Medicare, but cannot so easily receive info from Medicare. Before the mix up with Mrs. B’s living status, Mrs. B had been receiving a combined monthly payment of $933 for both her Social Security retirement and SSI benefit. Once Social Security received her record with a date of death, her retirement and SSI benefits stopped. This then also cut her off from her LTC Medi-Cal benefit resulting in her nursing home no longer getting paid.
Ruth thought she may be able to get the Social Security record cleared through a “backdoor” approach by going through her contact at her local Medi-Cal office, the Eligibility Supervisor, Becky, with whom she has worked for years. Becky explained that while she could change the coding for Mrs. B’s Medi-Cal benefits to start again, the code wouldn’t “hold” until Social Security changed the info in their system. Every time Social Security’s info would come through their Medi-Cal system, Mrs. B’s codes would go back to the incorrect info.
While correcting the erroneous “deceased” info in Medicare’s system took only 1 week to fix, rectifying records in the Social Security system took another 3.5 weeks and the involvement of other government entities, such as the Centers for Medicare and Medicaid Services and California Department on Aging. After 4.5 weeks, the mission was complete. Ruth received a call from Becky that Mrs. B’s LTC Medi-Cal had been re-instated, meaning that Social Security had updated their systems and the client was now receiving her Medi-Cal and Social Security benefits. Also, Mrs. B’s doctors were being paid, new referrals were made and care was resumed.
The case was a success, and again highlights both the extraordinary work HICAP does for its clients and the importance of having a knowledgeable and committed advocate who understands the systems and how to bring change and correct mistakes. We extend our big thanks to California’s Health Insurance Counseling and Advocacy Program, their staff and dedicated volunteers.