Health Care Horror - Letter To President

Dear Mr President,

    My name is Linda Fullerton, I am 54 years old, and I thought it was extremely urgent for me to share my story with you, especially today, since you are working so hard to get health care reform passed as soon as possible.  I know that there are some legislators in both parties who are unsure of how they should cast their vote on this issue.  It seems as you say, that the way big insurance companies are treating their customers is a huge part of the problem.  Since they have taken over the health care system, the problems and costs have spiraled out of control.  I agree totally with your views on that and the experience I am about to share with you, is living proof of that fact.

  My mother and I both get our health insurance through an HMO Medicare Advantage Plan.  We have different companies who administer our Medicare benefits.  I know there has been talk as part of this debate, that funding to these plans may be cut.  As part of your conversation on health care reform, you say that part of the reform you want to see,  is that you want to stop insurance companies from denying people coverage who have pre-existing conditions and stop the huge premium increases.  I totally agree with both of those things.  I also must tell you that these same companies, are taking money from the Federal government to subsidize and administer these Medicare Advantage plans, taking money from the American people, and then they are flat out cheating them out of their benefits, while breaking Federal Medicare regulations in the process.  The story I am about to share is a classic example of what our seniors, the disabled, and those who care for them have to endure on a daily basis.

    In March 2009 my mother became ill and was admitted to the hospital.  I am her power of attorney and health care proxy.  While she was in the hospital, she was treated improperly and given prescription medications that caused her serious harm and nearly killed her.  The state found the hospital negligent on several counts regarding her care, and I am going to be taking legal action against the hospital.  As a result of this improper treatment, my mother had to be admitted to a skilled nursing facility.  Under Medicare law a person is entitled to 100 days of skilled nursing care coverage after a 3 day qualifying hospital stay.  Since my mother was hospitalized for at least 2-1/2 weeks, she more than met this requirement.  She always paid her health insurance premiums on time and without hesitation.  Now when she needed help the most, the insurance company – MVP Health Care – denied her skilled nursing care coverage.  The reason they gave for denial had nothing to do with pre-existing conditions of any kind.  The coverage for skilled nursing care under her Medicare Advantage plan is 15 days – covered in full at no charge, and then 85 days at $65 co-pay/per day for each 3 day qualifying hospital stay.  Without this coverage, the charge for my mother to be in the skilled nursing facility to get the level of care she requires, is over $325.00 per day.  A huge difference as you can see.  As a result in large part from this denial of coverage, my mother has now had to go on Medicaid as well.

    I was outraged at this denial and not taking no for an answer, I filed an appeal, which was again denied.  Then the claim went to a third party contracted by Medicare called Maximus Federal Services, who by the way is just as corrupt as the insurance companies they are supposed to be policing, and they denied the claim as well.  I was determined to get justice and appealed again, this time to a Federal Medicare Appeals – Administrative Law Judge/ALJ.  On 10/22/09 he decided in my mother’s favor.  Oddly enough while I should have been overjoyed at his favorable decision, there was a problem that I was not aware of, and nobody alerted me about it – not the nursing home or the HMO, and I did not find out about it until during the ALJ hearing.  I thought all this time I was appealing a full 100 days denial of coverage, and the denial letter I received from the insurance company only listed the first day of admission to the skilled nursing facility on the paperwork they sent me.  They did not list a range of service dates – this is a tactic that can, as I found out the hard way, be used to cheat the claimant out of precious benefits if the case goes to court.  The nursing home where my mother resides, gets more money if a patient is private pay, than if they are paid by the insurance company, so they only put in a claim to the HMO for 21 days instead of the full 100 days of coverage that she was entitled to.  They also assumed that I would not win the appeal.  So when the Medicare Appeals ALJ made the favorable decision he could by law, only approve the 21 days that the nursing home put the claim in for, and not the full 100 days that I was appealing.  He then stated that I had the right without prejudice to file a new claim for the balance of the benefits that my mother was owed under the law which was 79 more days of coverage. 

    The nursing home submitted the new second claim to MVP Health Care for the balance of 79 days, and even though my mother received the same skilled nursing level of care during this time, that the ALJ approved in the first claim, MVP Health Care is again trying to cheat my mother out of her benefits and has denied this new claim as well.  Now I have to go through this whole nightmare process all over again.  I tried everything I could to get them to reconsider but they basically said that I will have to put in another formal appeal.  Their arrogant attorney spoke with me before I even filed the formal appeal this weekend, and told me that no matter what I do, they were going to continue their denial of coverage and that they would “see me in court.”  I have sent them copies of all the Medicare Laws and supporting medical records that prove my mother does in fact qualify for these benefits again – over 160 pages, but I have no faith that they will do right by her.  I am expecting that I will in fact have to take them to Federal court.

  This is an outrage to say the least!  Not only have I had to deal with almost losing my mother, but I have already spent almost 1 year of my life battling with this HMO trying to get them to follow Medicare regulations, and pay my mother the benefits that she is rightfully entitled to.  To this day, the battle still rages on, and no way to tell how much longer it will last.  This process is also taking a severe toll on my already compromised health, and at this rate, the stress of this whole nightmare will put me in the grave before both of my elderly parents.  As I am sure you know, that is what the insurance companies want.  By making the process as difficult as possible, they hope you will give up, so they can cheat you out of your benefits and keep all the profits.  My mother is on Social Security, there was no cost of living increase this year, and on the day MVP Health Care denied my mother her second claim for nursing home care, they also raised her premium from $61.40 to $92.00 per month for all of 2010.  Their main policy seems to be - deny coverage and raise premiums.

    You have also been stating that you want to close the dreaded Medicare Part D “donut hole.”  This issue has hurt both my mother and myself, as we both fell victim to it’s harsh reality last year.  I am on Social Security Disability and that is my only source of income.  For four months last year, I was in the “donut hole” and over ¼ of my Social Security Disability check each month had to be used to pay for my medicines.  I had to choose between paying for food, clothes and other necessities of life, or paying for my prescriptions.  Since I had to take these medicines or risk causing permanent irreversible damage to my health, I had to do without many of the other things mentioned.  We who are living under these conditions, cannot afford to wait another day for this gap to be closed.  I see that under the current proposals, this gap will not be closed fully for many years to come, and I find that to be totally unacceptable.  I am sure that if you ask the millions of other Americans that have had to endure this suffering as well, that they would agree with me.  I ask that you please make sure that any health care reform bill that you sign into law removes the entire “donut hole” gap immediately upon passage of the bill.  Our very lives depend on it!

    In spite of the horror story that I have just outlined, there are some good things about Medicare Advantage plans that actually do help those of us who have them.  Mine for example covers eye exams, eyewear, dental coverage, prescription drug coverage, important medical tests/exams and many other things that basic Medicare does not.  This type of extra coverage is crucial to the overall health and well being of a rapidly aging population who needs these services more than ever.  Many of these are things are preventative measures, which in the long run can reduce overall health care costs.  I ask that you please, before you propose to eliminate these plans, or reduce their funding, see to it that this “extra coverage” is then added to basic Medicare instead.

    Rest assured I will not give up this fight on behalf of my mother.  I won the first time around for her, and several times with my own HMO, the SSA, and auto insurance company for my own claims.  I have a perfect record so far – 5 wins for me – 0 wins for the others.  You are right - it takes courage to stand up to the big insurance companies/corporate America, put politics aside, and pass health care reform.  If I, a single 54 year old woman can stand up to these organizations and win, on my own, then why is it that our elected officials who are getting paid to represent the citizens of this nation are having such a hard time? 

    We both really know the answer to that question.  Instead of having the courage to do the right thing by the American people, they fear they will lose out on those big insurance company contributions come election time.  That fear is greatly misplaced.  They are supposed to represent us – not just their own self interests.  What they should really be afraid of is, that if they fail to give the American people true health care reform this time around, we will not forget that they let us down when we go to the polls again.  We have the ability to “fire” them for their failure to perform in our best interest.  As a result of their inaction, they too can face the fears that millions of Americans deal with every day in the unemployment line.

    The majority of the American people when they truly think about it, want some sort of health care reform.  The freedom it would give them to not have to worry about health coverage is priceless.  It would also boost the economy as Americans would not have to feel enslaved to dead end jobs they hated, just to get health care from their employers.  They could start more new ventures if they did not have to worry about how they would pay for exorbitant insurance premiums for their employees.  Health care reform was a major part of your campaign when you ran for President, and has been one of your major goals since you have taken office.  It is the right thing to do for the American people, and a noble and courageous act on your part for which you should be highly commended, and not chastised for.  Your main campaign slogan was “Yes We Can!”  I along with the majority of the country agreed with that statement on election day, so I say “Yes We Can” get health care reform, and I know you can find a way to make it happen.

    In closing, I hope you will please share my story/letter with the American people, and with Congress to remind them of how they should do the job that we elected them to do, properly.  I am the “canary in the coal mine” when it comes to these social issues and want to be the whistle blower for change.  I hope you will allow me to share my expertise from all that I have learned from this harrowing experience, much more than is outlined here, with you, and the Congress on a regular basis.  I know first hand, what needs to be fixed throughout this entire health care system – what works and what does not.  I have seen so much waste and fraud that your hair would stand on end.  I am also more than happy to testify before Congress should there be any hearings, and will speak to any media that you feel is proper to get this important message for change out to the public.  I hope one day soon we can meet or talk personally about these things.  Thank for you for your continued efforts to champion this extremely important life and death issue, and no matter what - please, please, please do not give up! 

Sincerely,

Linda Fullerton