Weisberg showed nothing but contempt for my folks by her refusal to allow them the rights that had been established for Medicare managed care beneficiaries. Weisberg's stamp of approval allowed Advocate to get away with violating numerous CMS regulations, thus expediting the harm done to my folks. I do not know what her motive was.
I supplied Weisberg with an abundance of written and audio testimony, as well annotated documents, that clearly showed that the Advocate had repeatedly failed to abide by numerous CMS regulations. Weisberg did not dispute the testimony and documents; she refused to acknowledge their existence!
My stepfather's Primary Care Physician and all of his specialists were employed by Advocate. Advocate owned his network hospital, Lutheran General Hospital. Advocate had a risk sharing agreement with my stepfather's Medicare managed care HMO (insurance company). Advocate was paid a monthly capitation per covered member to assume risk for all managed care services including professional and hospital costs.
My stepfather had surgery late in June 2003 at Advocate Lutheran General. His surgeon had informed me that he wanted my stepfather to receive acute physical therapy at Lutheran General's 6th floor rehabilitation unit after his surgery.
I was informed by the hospital staff members that my stepfather would be evaluated to determine if he fit the criteria for acute PT. (Acute PT is intensive.) I was later told that he had been evaluated and had been found not to be a candidate for acute PT. I was then advised that he would be sent to a skilled nursing facility where he would receive sub-acute PT. I did not file an Expedited (Fast) Appeal, because I had been told that acute PT would be too rigorous for him.
In March 2004, I found out that my stepfather had never been evaluated for the acute PT. Another Advocate employee advised me that he did not receive the acute PT because the HMO (insurance company) would not pay for it because the service was "out of network." (This individual did not realize that she was blowing the whistle on Advocate, her employer.) She arranged for me to receive a copy of his evaluation form, which had not been included in his medical records that I had obtained after his surgery. Advocate had lied to me in order to prevent me from filing a Fast (Expedited) Appeal. I will never know if the insurance company had advised Advocate that the 6th floor rehab center was not a part of my stepfather's network. (I think Advocate lied about that too.) Remember, Advocate was paying for the therapy, albeit paying itself. Acute PT is much more expensive than sub-acute. Regardless, if that were the case, we should have been notified in writing, and then been offered an alternative source for acute PT. If none was offered, I could have then filed an Expedited Appeal.
I brought this to the attention of former CMS Region V Medicare managed care manager, Bette Weisberg, and her crew. I provided Weisberg with a copy of the evaluation form, but she refused to acknowledge its existence. Instead, she claimed that no service had been denied. She even went so far as to claim that there was no such thing as acute PT!
According to the Centers for Medicare and Medicaid Services web site, all one needs is to think that they did not receive a service that they had thought that they should, and that is grounds for appeal.
I did not need to prove that Advocate had lied to me in order to avoid an Appeal. Another CMS employee told me that I would not have been able to file an appeal just because my stepfather had not received a service that I thought that he should. Obviously, this employee never looked at the CMS website. Furthermore, he could not get it through his thick head that my stepfather's surgeon was the individual who requested the acute PT.
Unfortunately, nobody I have contacted is interested in making anybody at CMS accountable for Weisberg and her crew's illicit actions. This was just one of them.
The Smoking Gun" and one of the documents Weisberg refused to acknowldege. It clearly states "insurance denied-out of network."
Weisberg insists no services were denied. I had never said that Lutheran General Hospital was not my stepfather's network hospital.
Weisberg implies that there is no difference between acute and sub-acute PT, because CMS does not recognize a difference, and the Merck Manual definiton of acute and sub-acute PT.