The Ombudsman Report - June 2022

All That Glitters Is Not Gold

by Kathleen Heren, Rhode Island Long-Term Care Ombudsman, Guest Blogger

Kathleen Heren

Have you noticed all the ads on television telling you about this new Medicare Advantage Plan? If you qualify, you can get more benefits than you have now with your present coverage. Who wouldn’t want extra goodies? They even tell you that if you qualify, you may even get money back in your monthly Social Security Check. The latest scam on seniors is all that it is.

In a report released Thursday, April 28, 2022, by the Inspector General’s Office of Health and Human Services they stated Medicare should pay more attention to these private insurance companies that have a pattern of denials of covered services. The report stated that 135 of the claims that were denied should have been paid.

The most frequent denials were for CT scans and MRIs. A subscriber had to wait five weeks for a CT scan approval to assess her Endometrial Cancer. This was endangering her life. Claims were denied when an elder was recommended to go to a skilled nursing facility for rehab. The doctor did not feel she could recover as well at home as she would in a facility. It’s unfortunate that the subscriber is not aware of an appeal process when denied. Seventy-five percent of all appeal cases were reversed by the HMO.

"It's unfortunate that the subscriber is not aware of an appeal process when denied [medical claims]. Seventy-five percent of all appeal cases were reversed by the HMO." --- Kathleen Heren

The insurance company used the excuse that the patient did not submit enough documentation to support the request for services. When reviewed by the Inspector General, those statements proved to be false. Another gimmick is to tell the subscriber that the drugs they are currently taking which have co-pays may have them eliminated by joining their plan. What happens is that the promise is only good for four weeks then it’s back to the co-pay - which could be even higher!

Be very wary of these misleading ads

In closing, using Joe Namath or movie stars to entice you to change your plan is the hook. Do you really think these movie stars have to worry about paying for their health care? Don’t jump into something before you know what the advantages of switching plans will have for you. The old saying of pay me now or pay me later is true.

There are some seniors who believe that Medicare pays for everything, and they don’t buy supplemental insurance. Then comes the day they are hospitalized, and the cost of care overwhelms them. If you are denied a claim, appeal it right away. You can contact Medicare; the number is on the back of your card. Please feel free to contact our office with any questions. If we don’t have the answer, we will direct you to someone who will.

My office is available to help you with any concerns you may have. Our number is (401) 785-3340, Toll-free (888) 351-0808. I can also be reached by e-mail:


Ms. Heren provides a monthly guest blog to Connelly Law Offices, Ltd. in which she discusses issues and topics that come across her desk as the Rhode Island State Long Term Care Ombudsman. The opinions expressed in our guest blogs are those of the author(s) only. They do not purport to reflect the opinions or views of Connelly Law Offices, Ltd. or its employees.

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