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 acompany that sells wheelchairs. He ordered a wheelchair after thesalesperson assured him that Medicare would reimburse him for the expense.He was surprised to find that Medicare would not pay for it. What wouldyou tell him about the procedure for getting a wheelchair under Medicare?
How would you help him with this situation?
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Case Study — Fran Tikk
Fran is 71 andon a federal employee group retiree plan with Blue Cross/Blue Shield(BCBS) for which she is paying a premium of over $150/month. She hashad numerous health problems in the past few years, and her plan does notprovide full coverage.
When Fran turned 65 in 2005, she called Social Security to see aboutenrolling in Medicare. She was told that she was not eligible for Medicarebecause she had not worked under Social Security. In 2007 a rep at herfederal BCBS plan told her she would be eligible for Medicare under herex-spouse who had worked under Social Security. (They had been married formore than 10 years.) Fran then went to her local SS office to inquire. TheSS worker confirmed that she indeed was eligible under her former spousebut would now face a penalty for not signing up back in 2005. Fran refusedMedicare 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 shehas spent down her savings on medical bills.)
Fran was recently told by member services at her federal BCBS planthat if she could get Medicare A&B, her BCBS would act as a supplementproviding full coverage at a lower cost. She could then drop down to a planthat would cost far less than what she is currently paying.
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Case Study — Jack R. Abbot
Mr Abbot is retired and having problems with his insurance coveringhis medical bills. He keeps getting denial notices for many of the serviceshe receives. He wants to meet with you to get some help with resolving thesituation.
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 thehospital he has been receiving physical therapy services in his home. Hewas told by his physical therapist, however, that the therapy will end nextweek. Mr. Scope thinks that he needs more therapy.
How would you help him?
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Case Study — Barbie Que
Barbie calls you at the SHINE office. She tells you she has beencovered under Blue Cross/Blue Shield’s Medex Gold plan because she takesa lot of medications. She is very satisfied with the Gold plan but is finding itdifficult to pay the premium on top of the expenses she has maintaining herhome. Barbie looked into the program through Social Security that helpspay for prescription costs, but tells you her monthly income of $1,725 andassets 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 andis retiring. He has just returned from Social Security and will receiveMedicare A and B. His neighbor has a Medigap Supplement 1 plan, so healso signed up effective on the first of next month when his Medicarebegins. He has three prescriptions: one is a brand, Advair, and the othertwo are generics. He has heard negative things about Part D, so he tells youhe may just pay for his prescriptions out ofpocket. His only income will be $11,900/year from Social Security, and he currently has $8000 in the bank.
How would you help him?
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Case Study - Jen Teal
Jen meets with you to talk about her prescription coverage. Shejoined a Part D plan last year but wants to find out if there is a better planshe can join this year. She takes a few expensive brands which she paid forin full during the donut hole at a cost of several hundred per month. Afriend told her she should have signed up for the plan that covers brandsduring the donut hole, so she wants to know if that’s what she should do thisyear.
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She explains that although her only income is Social Security of $1,450 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
- 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?
□Insurance
□Health Plan
□Medicare
□Employer Health Plan
- 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
- 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?
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