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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
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
Amanda Runge, EBS in Winnebago County, recently received a fully favorable decision for a client with an SSDI overpayment of over $114,000. The client, a 61-year-old man, had worked for many years for a friend. SSA alleged that this client had gone over the monthly substantial gainful activity (SGA) amount with his earnings for several years. However, this client's friend/boss had provided him with a lot of extra accommodations and even paid him for days in which he did not work. Amanda helped the client gather evidence of this, along with paystubs and a letter from his former boss, to send in with the appeal. The appeal was fully favorable, and the client no longer owes an SSDI overpayment.
Monetary Impact = $114,000
6/29/2023
Story #85
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
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