Case Study — Mr. Felix DeKatt
Felix has diabetes and has been seeing a podiatrist for the past three months for foot care. Recently Felix changed doctors and was asked to pay $75 for the office visit. Felix was sure that Medicare paid for these services since he had never received a bill from his previous podiatrist. When Felix questioned the billing clerk in the doctor’s office, he was told that Medicare does not cover routine foot care.
How would you help him?
Case Study — Mr. Cal Asthenik
Cal was having a hard time walking. He received a call from a company that sells wheelchairs. He ordered a wheelchair after the salesperson assured him that Medicare would reimburse him for the expense. He was surprised to find that Medicare would not pay for it. What would you tell him about the procedure for getting a wheelchair under Medicare?
How would you help him with this situation?
· Dr’s office is incorrect, since he has diabetes
· Medicare provides podiatry coverage for people with diabetes
· Contact Dr’s office
· Dr must prescribe
· Company must be Medicare provider
· Return wheelchair
· Make Dr’s appointment to discuss wheelchair need
Case Study — Fran Tikk
Fran is 71 and on a federal employee group retiree plan with Blue Cross/Blue Shield (BCBS) for which she is paying a premium of over $150/month. She has had numerous health problems in the past few years, and her plan does not provide full coverage.
When Fran turned 65 in 2009, she called Social Security to see about enrolling in Medicare. She was told that she was not eligible for Medicare because she had not worked under Social Security. In 2011 a rep at her federal BCBS plan told her she would be eligible for Medicare under her ex-spouse who had worked under Social Security. (They had been married for more than 10 years.) Fran then went to her local SS office to inquire. The SS worker confirmed that she indeed was eligible under her former spouse but would now face a penalty for not signing up back in 2009. Fran refused Medicare at that point because she could not afford it with the penalty. (Fran’s gross income is under $1000/month, and over the past few years she has spent down her savings on medical bills.)
Fran was recently told by member services at her federal BCBS plan that
if she could get Medicare A&B, her BCBS would act as a supplement providing full coverage at a lower cost. She could then drop down to a plan that would cost far less than what she is currently paying.
· May be eligible for MH (Standard, QI1) – check income and assets
· If yes, can enroll in Medicare A & B at any time
· MH will pay Part B premium and penalty
· Drop to lower federal plan
· If not MH eligible, must wait for GEP, effective July 1 and pay penalty
· Refer to MAP for Part B Late Enrollment Appeal
Case Study — Jack R. Abbot
Mr Abbot is retired and having problems with his insurance covering his medical bills. He keeps getting denial notices for many of the services he receives. He wants to meet with you to get some help with resolving the situation.
What information would you ask Mr. Abbot to bring to your meeting?
How would you help him?
Case Study — Mr. Perry Scope
Mr. Scope fell and broke his hip. Since his discharge from the hospital he has been receiving physical therapy services in his home. He was told by his physical therapist, however, that the therapy will end next week. Mr. Scope thinks that he needs more therapy.
How would you help him?
· Need to determine what he has for insurance;
® Ask to see his Medicare card
® Health Insurance cards
® Retiree Plan? If so, he must bring details of benefits
· Check denial notices (MSN, Explanation of Benefits)
· Make appropriate calls
· Must see doctor to get extension
· Doctor may prescribe additional therapy
Case Study — Barbie Que
Barbie calls you at the SHINE office. She tells you she has been covered under Blue Cross/Blue Shield’s Medex Gold plan because she takes a lot of medications. She is very satisfied with the Gold plan but is finding it difficult to pay the premium on top of the expenses she has maintaining her home. Barbie looked into the program through Social Security that helps pay for prescription costs, but tells you her monthly income of $1,725 and assets of $40,000 make her ineligible.
How would you help her?
Case Study — Al Falfa
Al meets with you at the SHINE office. He will be 65 next month and is retiring. He has just returned from Social Security and will receive Medicare A and B. His neighbor has a Medigap Supplement 1 plan, so he also signed up effective on the first of next month when his Medicare begins. He has three prescriptions: one is a brand, Advair, and the other two are generics. He has heard negative things about Part D, so he tells you he may just pay for his prescriptions out of pocket. His only income will be $11,900/year from Social Security, and he currently has $8000 in the bank.
How would you help him?
· Plan Finder search to compare cost of drugs in PDP vs Medex Gold
· If PDP saves significant amount, then discuss BCBS Medex Bronze (Supp 1) and PDP
· Can get Bronze at any time (continuous), and eligible for PA so can get PDP
· PA will also provide gap coverage
· If single, eligible for full LIS so assistance with drug plan premiums and co-pays
· LIS app
· Discuss Medigap CORE and HSN
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Case Study - Jen Teal
Jen meets with you to talk about her prescription coverage. She joined a Part D plan last year but wants to find out if there is a better plan she can join this year. She takes a few expensive brands which she paid for in full during the donut hole at a cost of several hundred per month. A friend told her she should have signed up for the plan that covers brands during the donut hole, so she wants to know if that’s what she should do this year.
· Friend is incorrect – no plan covers brands during the donut hole
· Prescription Advantage eligible (category S2) – will help in donut hole
· Provide and assist with Prescription Advantage application
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She explains that although her only income is Social Security of $1,650 per month, she has assets that make
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her ineligible for benefit programs. She lives in her own home and wants
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to stay there for as long as she can afford to. Although her assets
prevent her from getting any assistance, she uses her assets to help with her prescription costs and to maintain her home. How would you help her?
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Claims Processing, Appeals, Fraud & Abuse Quiz
1. While driving to work Josephine has a minor traffic accident. As a precaution
Josephine was transported to the hospital in an ambulance and was examined by a physician in the emergency room. Josephine gave the emergency room clerk her Medicare and Medigap insurance information. Several weeks later Josephine received a denial from Medicare for the services. Who pays first?
□ Auto Insurance
□ Health Plan
□ Medicare
□ Employer Health Plan
2. Harriet has been in the hospital for 4 days recovering from gall bladder surgery. The hospital staff has informed her that she is being discharged the following day. Harriet does not feel strong enough to return home and wants to appeal this discharge. To whom should she direct her appeal?
□ Medicare Advocacy Project
□ Medicare Part B
□ Livanta
□ Surgeon General
3. Mary Jones bas been receiving home health services for the past 6 weeks. She calls you because the home health agency informed her today that she will be discharged from receiving these services next week. Mary feels she still needs physical therapy. How would you help her?
Contact doctor to request additional services. Must see doctor and get prescription for additional sessions.
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