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Jennie Bowers in St. Croix County helped a client with a successful appeal following the denial of a medical procedure. Her client had had prostate cancer and had developed some severe and unpleasant side effects from the medications used to treat the condition. The client worked with his doctor for over a year to try and come up with alternate, non-surgical ways of treating the problems, but was unsuccessful. He had excess skin that had swelled up near his prostate area causing painful urination, difficulty maintaining cleanliness, and painful walking (due to rubbing). Ultimately, his doctors determined surgery was necessary to correct the problem. Medicare initially denied part of the surgical procedure as being “cosmetic." However, by obtaining medical records showing the client's many trips to the doctor regarding the problem as well as his many unsuccessful attempts at treating the issue using less invasive techniques, Jennie was able to demonstrate to Medicare that this surgery was entirely medically necessary for treatment of his pain and condition. The client agreed to let Jennie send in pictures of the condition (taken by his doctor) along with the appeal so that the reviewers could see the scope of the problems that the client had been dealing with. As they say, a picture is worth a thousand words! Upon seeing the pictures and reading the appeal, Medicare agreed that the surgery was not cosmetic, and approved coverage for the remaining $5,000 balance.
Monetary Impact = $5,000
10/31/2023
Story #127
Jessica Smith, EBS in Eau Claire County, helped a client successfully appeal the denial of her gastrointestinal testing. The client was 76 years old and experiencing symptoms initially diagnosed as mild food poisoning and expected to pass within a day or so. However, when her symptoms did not improve after a couple of days and actually worsened, she returned to her doctor's office and insisted on additional testing. Good thing the client was persistent because she actually tested positive for C difficile toxin, commonly known as “C-diff." The client received a phone call from an epidemiologist at Mayo Hospital in Rochester, Minnesota with instructions about starting a strong antibiotic regimen immediately due to the serious implications of the infection. Medicare denied the test as unnecessary; however, upon investigating the facts, Jessica found out that the client had met three of the five conditions in the Medicare Local Coverage Determination (LCD), even though it was only necessary to have met one of those five conditions in order for Medicare to cover the test. Jessica obtained a copy of the patient's medical records regarding the need for the test and sent in the appeal. Medicare agreed that the test was warranted and paid for the $816 claim. And since the client also had a supplement, she did not owe anything for the test after it was covered by Medicare.
Monetary Impact = $816
10/31/2023
Story #126
Leanne Grover, EBS for Barron County, worked with a client who had received a letter from Social Security in March requesting verification of employment for the previous three years. Leanne helped the client submit all of her wage documentation within a week after receiving the letter but, in August, the client received another letter saying she was ineligible for SSDI payments for several months during the review time frame. Leanne submitted the relevant paystubs again, only to receive an overpayment notice in September totaling more than $19,000. Leanne helped the client submit a reconsideration request and included sections from the POMS clarifying that vacation and sick time should not be counted toward earned wages. Upon reconsideration, SSA determined that there was no overpayment and that SSDI payments would be reinstated.
Monetary Impact = $19,000
10/31/2023
Story #123
Karen Nichols, EBS for Burnett County, was recently contacted by a client who had received Medicare Summary Notices (MSNs) stating that certain claims were being denied based on records of an insurance payment stemming from a car accident that happened more than ten years ago. The Medicare Benefits Coordination & Recovery Center (BCRC) insisted on documentation from the insurance company showing that the case was closed, but when the client contacted the insurance company, she was told that the company did not keep records that long. Karen helped the client follow up with the insurance company and convinced them to send a letter to the BCRC. The insurance settlement is now cleared off the client's record, paving the way for Medicare coverage of claims exceeding $200,000.
Monetary Impact = $200,000
10/31/2023
Story #121
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The second client, an 84-year-old man, suffered a fall at home and fractured his left hip and left clavicle. After hospitalization, he was transferred to a SNF for rehabilitation. About four weeks later, the client's MA plan issued a denial for further SNF services; however, the client had not met his rehab goals and was not yet safe to return home. He continued to receive daily skilled therapies for another two weeks, and then his therapy was cut down to three days per week. Kathryn assisted the client with an appeal and after an ALJ hearing, the client got the additional two weeks covered.
10/31/2023
Story #120
Kathryn Noll-Arias, EBS in Winnebago County, recently had two successful SNF appeals. The first client, an 88-year-old man was in the hospital for meningitis and an infected hematoma from a fall. He was diagnosed with Methicillin-Sensitive Staphylococcus aureus (MSSA) and was started on an IV antibiotic. He was discharged to a SNF for rehabilitation and skilled nursing care for his wound and IV antibiotic. When his therapies were reduced from five days per week to three, the SNF issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) stating that Original Medicare would no longer cover his SNF stay. However, the client was still at a skilled level of care for his IV antibiotic. Kathryn assisted the client with appealing and after an ALJ hearing, received a fully favorable decision covering the client's entire stay at the SNF.
10/31/2023
Story #119
Jennifer Trasser, EBS in Outagamie County, assisted a 78-year-old woman to get her entire skilled nursing facility (SNF) stay fully covered. The client had a total knee replacement and was then discharged to the SNF for daily skilled rehabilitation. After only one week, the client's Medicare Advantage (MA) plan issued a denial stating that her SNF stay would no longer be covered; however, the client had not progressed enough at that point to be able to safely return home. She continued to get daily skilled therapies for an additional 10 days, made progress, and then was safe to return home. Jennifer assisted the client with the appeal and at the hearing, the client's MA plan agreed to full coverage of the client's stay at the SNF.
Monetary Impact =
10/31/2023
Story #118
Mary Velcich, EBS in Green County, helped a client successfully appeal part of an overpayment of over $5600. The client retired mid-year and began receiving early Social Security Retirement benefits that month. In addition to her final paycheck, the client received a large payout for her unused sick days. Mary determined that SSA used the yearly earnings test to determine that the client had been overpaid for the entire year. However, because the client was only retired for part of the year, SSA should have used the monthly earnings test, which meant that the client was only overpaid in the month she retired. Mary helped the client obtain records from her employer about her last paycheck and unused sick days and submitted a reconsideration to SSA. SSA agreed, and the client was relieved that she didn't have to repay the entire overpayment amount.
Monetary Impact = $5,600
9/29/2023
Story #115
Mary Rheinschmidt, EBS of Lincoln County, achieved another win for a client with a Skilled Nursing Facility (SNF) denial. The client had entered the SNF after contracting Covid-19 pneumonia, which exacerbated his COPD (on top of also undergoing treatments for cancer). His Advantage Plan, Security Health Plan, used its naviHealth algorithm to predict he would only need 14-18 days in the SNF, despite his doctors ordering 4-6 weeks of skilled rehab. Sure enough, on the 16th day, the client received notice that SHP would no longer cover his stay despite him being a high aspiration risk and having dangerously low oxygen levels. The client was afraid to pay out of pocket, so he and his family scrambled to get him home (against doctors' orders). Mary helped the client gather all medical information to support his case – and for the first time in GWAAR history – Livanta (the QIO) reversed the Advantage Plan's denial, which meant that Security Health Plan was required to pay for the outstanding days.
9/29/2023
Story #114
Mindy Shrader, EBS in Sauk County, recently helped a client whose spouse is in a nursing home request an additional income allocation at a fair hearing. Although the client is still working, she and her husband have high monthly expenses. Mindy helped the client put together a budget that showed how much additional income she would need in order to afford her living expenses. The ALJ found the budget reasonable and allocated the additional money the client requested.
9/29/2023
Story #113
Kathy Schultz, EBS of Langlade County, helped a client eliminate her Medicare Part D Late Enrollment Penalty. The client was assessed a Part D LEP because it did not have the information regarding her SeniorCare coverage. The client's friend had tried to help her appeal, but thought the Part D LEP was assessed because she was late on her Part D premium payments (which she was not). After receiving a denial, they came to Kathy, who helped her submit another appeal with the correct proof of SeniorCare coverage dates. C2C Solutions, however, gave this appeal a new number and denied due to it being past the appeal deadline. Kathy worked with her BSSA to draft a good cause late appeal based on the client's diligent work trying to resolve the issue since January. C2C Solutions ultimately agreed, and nine months later her LEP was removed.
Monetary Impact =
9/29/2023
Story #112
Kathy Cummings, EBS in Columbia County, recently helped a client obtain coverage for a skilled nursing facility (SNF) stay after an Advantage plan denial. The client was expected to need 12 weeks of daily physical therapy and occupational therapy after a fall at home left her with a broken leg and ankle, but her Advantage plan denied coverage after only three weeks. As a result, the client discharged home from the SNF after only six weeks. Kathy worked with the client's family to obtain medical records and prepare for an ALJ hearing. The morning of the hearing, the client's family received a letter from the plan stating that the client's entire SNF stay would be covered!
Monetary Impact =
8/31/2023
Story #108
Mindy Shrader also helped a client receive a fully favorable Medicare appeal of a Skilled Nursing Facility (SNF) coverage denial. The client needed daily occupational therapy, physical therapy, and wound care after a surgery for a broken leg so that he could return home and begin chemotherapy. However, his Medicare Advantage Plan terminated coverage after only 16 days. Mindy helped the client's family obtain medical records and prepare for the ALJ hearing, which took place in February. However, when they had not received a decision in May, the BSSA called the ALJ's assistant, who said that the hearing decision had already been mailed but that she would fax a copy of the decision. When the decision still had not arrived weeks later, Mindy helped the client's family work with Sen. Baldwin's office to obtain a copy of the decision, which finally arrived via mail to the BSSA's office with a July postmark. The decision was fully favorable, giving the client an additional two-and-a-half weeks of coverage, and the client's family was thrilled!
Monetary Impact =
8/31/2023
Story #107
Jerri Sokol, EBS of Iron County, helped a client resolve a Medicare billing error totaling near $430. The client had received a blood test that tested for multiple upper respiratory conditions. When the client received his Medicare Summary Notice (MSN), the reasons for denial were confusing, and it was coded with a GY-modifier, which means statutorily not covered by Medicare. Researching the National and Local Coverage Determinations (NCDs and LCDs) showed that this type of test needed a specific modifier, and not the GY-modifier. Jerri helped the client contact the provider and ask them to re-bill using the correct billing code, and they waived the bill in full.
Monetary Impact = $430
8/31/2023
Story #105
Gail Sauerman, EBS of Taylor County, helped a client receive a favorable Medicare decision totaling over $2,500. The client had received a Rhinophyma reduction procedure due to soft tissue collapsing his airway and making it difficult to breathe. Medicare, however, denied the claim, determining the nature of the procedure was cosmetic. The client had been diligently trying to get coverage, but was having no success. Gail gathered the critical medical documentation to prove why the client's procedure was medically necessary and helped him submit a good-cause late appeal due to his ongoing efforts to resolve the matter on his own. As a result of this appeal, Medicare paid the claim in full.
Monetary Impact = $2,500
8/31/2023
Story #102
Mary Rheinschmidt also helped a client reduce her medication bill substantially. The client came to Mary because she'd been charged roughly $18,000 EACH for two Stelara injections. The injections had previously been covered; she was used to paying roughly $1,500 out-of-pocket. However, a Medicare regulation change meant that Stelara injections were no longer covered. The change went into effect in Wisconsin in October, 2021 and she received an injection in November. She was understandably shocked to receive a bill for over $18,000 afterwards. The client was due for another injection in February, 2022, and the provider assured her it would be covered this time. The client, however, received yet another denial and a bill for $18,000. Mary left absolutely no stone unturned to help get coverage for the bills. This included filing multiple appeals with Medicare, requesting patient assistance, and helping the clients contact their legislators. In fact, Mary spoke to a worker from Tom Tiffany's office on behalf of the clients about the issue. Shortly after, Mary learned that the provider agreed to drop the $36,000 charge to just $9,000. At this time, it is unclear if the Congressional inquiry prompted the reversal, or whether the provider waived a portion of the bill, used patient assistance funds, or some other remedy. What we do know is that Mary worked for over a year on this case to get a just result, and the clients were thrilled to have the bill reduced to a more manageable amount.
Monetary Impact = $27,000
8/30/2023
Story #101
Mary Rheinschmidt, EBS of Lincoln County, helped a client receive reimbursement for a Skilled Nursing Facility (SNF) denial by an Advantage Plan. The client had entered the SNF after hip replacement surgery and his doctors recommended he receive at least four weeks of physical and occupational therapy at a skilled nursing facility. Security Health Plan, however, denied coverage after just 16 days. The client ended up needing 25 days in the SNF before he could safely go home. Mary worked with the client to gather all necessary medical documentation for the appeal, which was taken to the ALJ hearing stage. The day of the hearing, Security Health Plan agreed to pay the denied days – a total of over $2,600.
Monetary Impact = $2,600
8/31/2023
Story #100
Karen Nichols, EBS for Burnett County, met with a client who was having problems with billing for hip replacement surgery. Her Medicare Advantage plan was insisting that the procedure needed to be billed as inpatient surgery, but the surgery center was insisting that it could only bill the procedure as outpatient because it was a Critical Access Hospital. The hospital had appealed the denial to the plan, but the client had never directly appealed for herself. Karen contacted the plan and was told that the plan would allow the client to submit an appeal even though the deadline had passed. Karen contacted her program attorney who helped research the procedure and discovered that Medicare rules allowed this type of hip surgery to be billed either as inpatient or outpatient. Karen then helped the client write up and submit an appeal letter. With clarification that the surgery could be billed as outpatient, the plan reversed its denial and agreed to cover the charges. That decision reduced the client's bill from more than $37,000 down to $97.
Monetary Impact = $36,000
7/27/2023
Story #98
Jodi Kautzer, EBS in Calumet County, assisted a 67-year-old woman in getting a refund of over $720 for registered dietitian sessions that should have been covered by her Medicare Advantage (MA) plan. The client called her MA plan and was told that she would have up to six sessions covered by a particular provider. However, the provider submitted the claim incorrectly, and the claims were denied. The provider collected the money from the client and was less than helpful in assisting with resubmitting the claims. Jodi worked with the client for months to appeal to the MA plan and get the MA plan to work with the provider to get the sessions covered. The client received a refund check in the mail for the services that she was promised.
Monetary Impact = $720
7/28/2023
Story #95
Kris Schiek, EBS in Oneida County, helped a client successfully appeal an SSI overpayment of over $14,000. Kris helped the client obtain bank statements dating back to 2020 to show that SSA incorrectly counted his COVID-19 stimulus payments as available resources. Kris's supervising attorney created a table to show how the stimulus checks kept accumulating and, because they are excluded resources, he should not have been assessed an overpayment for not spending them down. SSA agreed, and issued a favorable decision in less than two months.
Monetary Impact = $14,000
6/29/2023
Story #91
Pam Fuchs, EBS in Sauk County, helped a client successfully appeal an SSDI overpayment in a case that took nearly two years to resolve. The client was injured while working in another state many years ago and received worker's compensation (WC) after that. She later moved to Wisconsin and applied for SSDI benefits after her WC payments had ended. SSA sent a letter to her representative payee asking for information about the WC payments, but the representative payee had significant medical issues and was unable to respond to that letter. As a result, SSA assumed the client was receiving WC payments and SSDI benefits at the same time without any offset calculated. Because the overpayment notice was so vague, Pam helped the client request reconsideration because SSA had not provided enough information for us to evaluate whether an overpayment had actually occurred. SSA responded by asking for records of the client's WC payments. Pam tried to track down the records, but the client's former employer, medical providers, and WC attorney no longer had any records. She was finally able to obtain records from the state where the work injury occurred, which showed that the client had not been receiving any WC payments at the time she applied for SSDI. SSA agreed, and not only did the client no longer have an overpayment issue, but SSA actually owed her some money!
6/29/2023
Story #89
Melissa Chase, EBS in Fond du Lac County, recently helped a 72-year-old client with an SSI termination and pending overpayment. SSA continued to count this client's COVID-19 stimulus payments as a resource, and they also counted an extra vehicle that the client did not actually own. Melissa worked with the client and SSA for months to try to get this issue resolved. Finally, Melissa helped the client appeal and send in a statement regarding these issues. One week later, the client received backpay of almost $3,500 and her SSI payments resumed.
Monetary Impact = $3,500
6/29/2023
Story #86
Jennifer had another successful case outcome where she assisted a client in getting thousands of dollars in medical bills covered under Medicare. The client, a 71-year-old man, has Original Medicare and had a worker's compensation issue ten years prior that had since been closed. This client's claims kept getting denied by Medicare because Medicare had his worker's comp insurance listed as a primary payer. The client and his doctor had both tried resolving the issue with Medicare and they both also submitted several appeals of these denied claims. The appeals were denied, and the next step was to request an administrative law judge (ALJ) hearing. Before doing that, however, Jennifer tried once more to resolve the issue with the BCRC and asked the provider to resubmit the claims. The claims were approved and paid, and the issue was fully resolved for this client.
Monetary Impact = $1,000
Story #83
Jennifer also recently received a fully favorable decision for a Skilled Nursing Facility (SNF) appeal. The client, a 74-year-old woman, had suffered a stroke and was subsequently admitted to a SNF for rehabilitation and daily skilled cares on her Percutaneous Endoscopic Gastrostomy (PEG) tube. The client's Medicare Advantage (MA) plan denied further SNF coverage after about three weeks in the SNF. Even though the client had stopped receiving daily skilled physical, occupational, and speech therapies, she still required daily skilled cares on her PEG tube and was not yet safe to return home. At the hearing, the beneficiary's MA plan tried arguing that the client's PEG tube did not qualify for Medicare SNF coverage because it was a chronic condition that the beneficiary was expected to have for life. This, however, was not anywhere in the Medicare regulations. After the hearing, the client received a fully favorable decision stating that she was eligible for Medicare SNF coverage for the full 100 days allowed by Medicare and her MA plan.
6/29/2023
Story #82
Mindy Shrader helped a client successfully complete a Homestead Tax Credit appeal. The client's tax preparer made an error on the client's tax return that resulted in an incorrect Homestead Tax Credit amount. The tax preparer refunded the fee the client paid but would not fix the return. Mindy helped the client submit correct documentation to the WI Department of Revenue, and the client received a favorable decision within a week, giving her an additional $240!
Monetary Impact = $240
4/28/2023
Story #68
Mindy Shrader, EBS in Sauk County, recently received a fully favorable Medicare appeal of Skilled Nursing Facility (SNF) coverage. The client was a 71-year-old man admitted to the SNF for rehab after surgery to treat a broken leg. After nine days in the SNF, his Medicare Advantage Plan terminated coverage even though he was not yet ready to return home, and his providers believed that daily skilled services were still medically necessary. With the help of her BSSA, Mindy helped the client's family with an ALJ hearing and received a fully favorable result that gave the client an extra month of coverage.
4/28/2023
Story #67
Maria Meyer, EBS of Portage County, recently assisted a client through a Skilled Nursing Facility (SNF) denial case, with a favorable result. Due to the high volume of SNF denials, some clients and their representatives have been provided with self-help guides to navigate the SNF denial process on their own. In one of these cases, Maria served as an advocate under the direction of her BSSA. Maria helped the clients obtain medical documentation, communicated with therapists, and facilitated the telephone hearing. At the beginning of the hearing - without any questioning or testimony - the insurance company agreed to pay the full amount for the denied services, which was roughly $19,000.
Monetary Impact = $19,000
4/28/2023
Story #65
Joanne Welsh, EBS in Richland County, helped a client successfully appeal his Part D late enrollment penalty. The client had been on SeniorCare for a number of years but had not filled out the plan's paperwork correctly to report the creditable drug coverage. Joanne helped the client appeal to C2C Solutions, which found that the client was not required to pay a late enrollment penalty.
2/28/2023
Story #55
Mary Kempf, EBS in Sheboygan County, recently had success helping a client receive an almost $8,000 refund that they were due from a skilled nursing facility (SNF). The client's spouse noticed that the client's supplement paid the SNF under the 30-day mandate, but the SNF would not refund this money to the client. Mary advocated on behalf of the client over several months with no luck. She finally called the SNF's out-of-state corporate office who got involved to issue the refund to the client.
Monetary Impact = $8,000
1/25/2023
Story #52
Leanne Grover, EBS in Barron County, helped a client successfully appeal a denial for air ambulance services. The man was vacationing in New Mexico when he had a medical emergency that required specialized surgical care. He was flown from a small local hospital to a larger facility in downtown Albuquerque. Medicare denied coverage for the air ambulance because he had not been taken to the nearest alternative hospital. Leanne was able to get letters from each of two closer hospitals stating that they would not have been able to provide the level of care the patient needed. The claim was approved at the redetermination level to cover air ambulance costs exceeding $99,000!
Monetary Impact = $99,000
11/30/2022
Story #42
Leilani Amundson, EBS in Dane County, recently received a fully favorable Medicare appeal of Skilled Nursing Facility (SNF) coverage. Leilani's client is a 72-year-old man who had to have an amputation of his leg above the knee. After surgery, he was moved to a SNF for rehab. After about two weeks in the SNF, his Medicare Advantage Plan terminated coverage; however, he was not yet ready to return home—he had not made enough progress in therapy, nor were his home modifications completed. He remained in the SNF an additional nine days receiving daily skilled therapies all while his family scrambled to complete home modifications. Those extra nine days left this client with a bill of over $3,000 for the uncovered room and board. With the help of her BSSA, Leilani assisted the client with an ALJ hearing and received a fully favorable result.
Monetary Impact = $3,000
10/30/2022
Story #39
Tiffany Scully, EBS in Dane County, also assisted a 63-year-old client with a good cause late appeal for an SSDI appeal. (Note: EBS typically do not help with SSDI appeals, but Tiffany got permission from her BSSA to assist in this narrow circumstance). The client was referred to the EBS Program by a nurse practitioner at a local cancer treatment clinic who tried to assist him with a phone appointment to apply for disability, but they were unable to get through to the claims rep due to phone issues and missed their scheduled appointment. When Tiffany and the client contacted the Madison SSA FO to reschedule, the claims rep informed them that the record showed the client already applied for SSDI in August 2021, based on a history of seizures. His claim was denied in March 2022. The client did not recall ever applying for SSDI, even though the forms had been signed by him, and he never received the denial notice. Tiffany explained that while the original claim was still pending, in November 2021, the client had been diagnosed with metastatic melanoma. During the call with SSA, the claims rep consulted with the FO manager who recommended submitting a good cause late appeal rather than a new disability application. With the client's permission, Tiffany consulted with the nurse practitioner at the cancer clinic who confirmed that the client met and exceeded the criteria under the compassionate allowance listing for skin malignant melanoma with metastases. After consulting with her program attorney, Tiffany met with the client and completed the necessary forms to request the good cause appeal, then faxed everything to the Madison FO and indicated that it was a TERI case. After making numerous calls to the FO over the course of two months requesting an update on when the claim would be sent to the DDB, Tiffany utilized the escalation process, and the area work incentives coordinator ensured that this process was completed. Within a few days of receiving the claim, the DDB issued a favorable decision which the area work incentives coordinator communicated to the EBS. The client is very pleased as his monthly Social Security benefit increased significantly under SSDI. Prior to the appeal, he had been receiving early retirement benefits, and, after paying his rent each month, he had less than $200 remaining for his other living expenses, making it difficult to make ends meet.
10/30/2022
Story #38
Mary Rheinschmidt, EBS in Lincoln County, helped a client reduce her divestment penalty period by 104 days! The client came to Mary to apply for LTC Medicaid. It was first discovered that her long-term burial insurance was not checked as irrevocable, so the client was over the asset limit. Mary quickly helped resolve this with the funeral home and submit the documentation to the Consortium. The next issue was the client had made numerous loans to family members within the lookback period. All of the loans were verbal, and only some had been paid back in full. Mary helped gather all of the client's bank statements, copies of checks, and client's notes for the past five years, and painstakingly reviewed them with her supervising attorney. Mary also helped the client request some additional repayments by the family members, further reducing the total divested amount. IM had originally assessed a divestment penalty period of 168 days, but with Mary's detailed work, they were able to reduce the penalty period to 64 days. Because the client had her functional screen in June, her penalty period had already been served, and her Family Care started in August. The family was thrilled!
8/31/2022
Story #26
Emily Reuter, EBS in Grant County, recently won a Medicaid fair hearing about a case involving a divestment. The client's husband had advanced dementia, and although she had been providing nearly all of his care in their home, his condition had worsened, and she was unable to provide 24-hour care herself. The ADRC helped with the Family Care application, but the client had sold the couple's home to their grandson a few months before because they could not afford to keep paying the mortgage. The client explained that she was worried that if they lost their home to foreclosure, they would have nowhere to live. The couple was paying rent to their grandson to continue living there. The sale price of the home was equal to the outstanding balance on the mortgage, which was a little less than the assessed value. Income Maintenance, however, used the current Zestimate on Zillow to set the fair market value for the house, turning what should've been a $12,000 divestment penalty into a $111,000 divestment! IM then denied a subsequent undue hardship waiver request, saying that the grandson could just give the house back. Emily helped the clients request a fair hearing to dispute IM's determination of the fair market value of the house and argue that the sale was not done to qualify for Medicaid. The administrative law judge agreed that IM's use of the Zestimate was inappropriate and that the sale of the house was an allowed divestment because it was not done with the intent to qualify for Medicare. Thanks to Emily's hard work and advocacy, the client's husband is now getting the care he needs!
Monetary Impact = $100,000
8/31/2022
Story #24
Eau Claire County EBS Jessica Smith persisted in assisting a woman with her ambulance appeal until they received a successful decision. The woman had a medical history of chronic heart failure, severe aortic stenosis, a heart murmur, and kidney failure. On the day of service, she was experiencing left-sided chest pain, back pain, and believed she was having a heart attack. Her husband called 911 so that an ambulance could take her to the hospital as soon as possible. Sadly, her adult son had just passed away two weeks prior due to heart disease, which was very prevalent in her family history. The ambulance company had correctly billed the claim as “advance life support—emergency transport" due to the fact that she was given a 12-point ECG during the ambulance ride which indicated tachycardia. However, the ambulance company also submitted the claim to Medicare with a “GY" code at the end meaning “statutorily not covered by Medicare." Due to the “GY" code, Medicare denied payment for the claim. Jessica collected the Medicare Summary Notice, the ambulance run report, and medical records as evidence. She then helped the couple to appeal to Medicare twice only to receive denials by both NGS and also C2C Solutions. However, Jessica knew that this claim should have been covered by Medicare because there is a presumption of Medicare coverage for ambulance rides when the person can only be moved by stretcher (which was the case here), and when the patient exhibited signs and symptoms of acute cardiac distress or chest pain. Jessica helped the client to request an Administrative Law Judge (ALJ) hearing. Prior to a hearing being scheduled, the ALJ issued an on-the-record decision, meaning that he had reviewed the file and exhibits that had been submitted and felt that a hearing did not need to be held because he already had sufficient information to make a favorable decision. After a year and a half of appealing, Jessica and the client finally received a fully favorable decision.
6/30/2022
Story #18
Kayli Williamson, EBS in Polk County, helped a client successfully appeal a $5,500 SSI overpayment notice which occurred between 2019 - 2021. The client had been alleged to have been over the $2,000 resource limit due to having too much money in his bank accounts and for owning a camper. Kayli wasted no time in digging into this case, and upon investigation discovered that the camper had recently been assessed by a professional who worked in the camper buying and selling industry. This professional had estimated the camper to be worth $0 due to its extensive roof and structural damage, bad tires, and irreparable fifth wheel due. The estimate indicated that at best the camper would only be worth money for metal scrapping if brought into a recycling center. Furthermore, the EBS found out that the camper was supposed to be an asset owned by his ex-wife given that the terms of their divorce judgment said the camper would belong solely to the ex-wife after the divorce was final in 2006. Therefore, the client had no legal right to sell or transfer the camper as doing so would be in violation of the divorce court order. Finally, Kayli discovered that the reason that the client's bank account was over the limit was due to stimulus money he had recently received. The stimulus money should have been an exempt resource for SSI for 12 months after the date it was received. Shortly after sending in the appeal, Kayli and the client were informed that their reconsideration request had been fully successful. The client was thrilled.
Monetary Impact = $5,500
6/30/2022
Story #17
Joanne Welsh, EBS in Richland County, helped a client successfully appeal an SSI overpayment. The client had received an inheritance many years ago, which caused her to lose SSI eligibility at that time. Over time, the client gradually spent the inheritance on her living expenses. When that money was gone, she reapplied for SSI. Although she began receiving benefits, SSA later decided that she still had the money from the inheritance, which put her over the asset limit. Joanne helped the client prepare a summary of how she had spent the money over several years and request reconsideration. SSA agreed that the client had not been over the asset limit when she reapplied for SSI, reinstated her benefits, and determined that she was owed over $1,600 in backpay for the months her benefits were stopped after she received the overpayment notice.
Monetary Impact = $1,600
6/30/2022
Story #15
Mindy Shrader, EBS in Sauk County, recently received a favorable decision from SSA on an appeal of a client’s Medicare start date. The client was QMB eligible, and Mindy helped the client request conditional enrollment into Part A in April 2021. Her QMB enrollment started June 1, 2021. Unfortunately, SSA ignored the conditional enrollment request, and started the client’s Medicare before her QMB started, even though the client did not have a SEP and was not in a Medicare enrollment period. The client is not eligible for premium-free Part A, so this left her with a very large premium bill. When SSA was unable to fix this, Mindy helped the client request reconsideration. After many months in the processing center, the client received an updated Medicare card with the correct start dates and a letter explaining that she no longer owed any Medicare premiums.
Monetary Impact = $510
5/31/2022
Story #14
Jessica Flores, EBS in Door County, recently worked to informally resolve a case involving Medicaid patient liability. The client had Intuitional Medicaid since mid-2020. In April 2022, he received his first bill from the nursing home for multiple months of his patient liability costs. This was alarming to his wife and his daughter, who is also his POA, because they had not received notice. They tried contacting the consortium but were unable to get the issue resolved. The EBS worked to find that due to workarounds and out-of-the-norm COVID-19 processing, the CARES system never kicked a letter out to the member, and therefore, he was never notified of his patient liability obligations properly. The EBS contacted the IM worker assigned to this member’s case and they discussed options that he may have. Since the error was caused by agency processing, IM agreed to manually override his liability billing for January-April 2022. This resulted in saving him over $6,700.
Monetary Impact = $6,700
5/31/2022
Story #13
Tiffany Scully, EBS in Dane County, worked with a client who had an IUD placed as part of a hysteroscopy procedure. The IUD was denied by Medicare as it was coded for prevention of pregnancy instead of a medically necessary procedure, which this was. The client went to the EBS after the deadline for filing an appeal. The EBS helped the client contact the hospital billing and they sent it back to be recoded. When the EBS later called Medicare SHIP, she was told that the claim was reprocessed but the procedure code was the same and it was denied for the same reason. The client and EBS contacted the billing dept and were told that they had adjusted the charge off since they didn’t have her sign an ABN. She was very happy to save almost $600!
Monetary Impact = $600
5/31/2022
Story #12