| Home | About Us | Benefit Check Up | Story Bank | Find Your BenSpec | Contact Us |
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.
10/31/2023
Story #118
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
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
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
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, 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
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
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
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