The Center for Medicare Advocacy claims in a federal lawsuit that U.S. Secretary of Health and Human Services Kathleen Sebelius denied its clients a meaningful review of their Medicare claims during the first two levels of appeal.
The class action filed last week by four Connecticut plaintiffs alleges they can’t get a meaningful review of their cases and instead receive an initial denial of coverage. The lawsuit claims that the combined denial rate for home health care coverage at the first two levels of review is about 98 percent.
The complaint states that the denial rate for traditional Medicare has been “rapidly increasing in recent years, coinciding with the implementation of a new administrative review process for Parts A and B of Medicare.”
The new review system was supposed to be more efficient, but what it’s done is “preclude beneficiaries from obtaining an efficient and meaningful review of their claims by requiring them to take their claims to the third level of review, a hearing before an Administrative Law Judge, if they want any realistic chance of coverage.”
Most of the center’s clients “do not have the time, resources, or advocacy support” to take their claims to that third level of review, according to the lawsuit.
“Older people and people with disabilities are going without necessary care because they’re being wrongly denied coverage and either drop out of the years-long appeals process, waiting for a hearing, or impoverish themselves to pay for care,” Gill Deford, litigation director at the Center for Medicare Advocacy, said. “The sheer number of beneficiaries who are forced to deal with this time-consuming, meaningless appeals structure compelled us to take action to seek meaningful reviews earlier in the appeals process.”
The U.S. Department of Health and Human Services was not immediately available for comment.
Carolyn Hull, the lead plaintiff in the case, lives alone in a trailer where she is homebound. The 79-year-old woman suffers from “severe orthopedic problems in her lower extremities.” Her doctor ordered home health aides to assist her one to three times a week.
According to the lawsuit the aides would help her with activities of daily living such as bathing, dressing, grooming, and toileting. More importantly they would check the wounds on her legs.
“During their visits, the nurses measured Ms. Hull’s wounds, noted color and any drainage, and checked for signs and symptoms of infection,” the lawsuit states.
The U.S. Department of Health and Human Services denied Hull coverage for home care services five times. She appealed the denials and Medicare determined that she was not “homebound” because she leaves the house on rare occasions “to attend the wound care clinic.”
A request for a hearing with an Administrative Law Judge was filed in January.
“Most beneficiaries don’t have the resources, time or support to take their claims all the way to an Administrative Law Judge, making the first two levels of review vitally important,” Judith Stein, executive director of the Center for Medicare Advocacy, said. “’Rubber-stamping’ appeals deprives a huge number of people a legitimate review process and harms those who depend on Medicare coverage for critical health care and to maintain their quality of life.”