A Win for Charlie

Charlie was in his seventies when his health began to take a slide.  This retired restaurant owner from Clifton, New Jersey developed diabetes which became very difficult to control.  He dealt with amputations of both legs and a myriad of other health problems.  On paper, it looked like Charlie was in terrible shape, but in person, we had never met someone so spirited and positive!

Despite his health issues and setbacks, Charlie was forging ahead with physical therapy in a rehabilitation facility.  He was making slow but steady progress, trying his hardest every day to improve his condition so that he could go home, even if it meant he needed prosthetic legs to walk again.

Unfortunately, Charlie’s managed Medicare plan didn’t see things the same way.  After just a few weeks of in-patient rehabilitation, they decided that Charlie didn’t qualify for continued in-patient therapy and told him that they would stop payment in a few days.

Charlie’s therapists didn’t agree…and neither did Charlie or his family.  How could a doctor at the insurance company, who was just reviewing paper records and had never laid eyes on Charlie, make such a drastic decision when the therapists working with Charlie every day felt that more therapy would help him?  Charlie’s therapists and family appealed this decision and were denied by the same insurance company that made the first decision to stop therapy.  That’s when the family contacted us.

We requested a Medicare hearing before an administrative law judge whose only job is to consider Medicare-related disputes.  We requested medical records and reviewed everything in detail, formulating a case for overturning that denial.  We jumped through all of the hoops and the hearing eventually took place over the telephone with the judge, who was in Cleveland, Ohio.   The doctor who made the decision to stop services participated in the telephone hearing as did we, as Charlie’s representatives.  All participants were sworn in and presented their arguments.

Two weeks later, we were pleased to learn that Charlie was approved to continue his in-patient rehabilitation and that his managed Medicare plan was required to pay for it – he received the therapy he needed in order to return home.  A win for Charlie!