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Medicare can be intricate maze to navigate

Nanticoke woman’s ordeal shows determination and appeals will get results.

Anna Jesse describes the problems she encountered trying to have her claim with Advantage Medicare settled.


When 64-year-old Anna Jesse of Nanticoke was told – like countless others – that she did not understand her Medicare Advantage insurance plan, the former employee benefits administrator went into action.

She did understand her plan, she said, and was determined to prove it.

After a hospital visit in mid-May, Jesse became caught in a web of conflicting information about payment of her bill.

The billing department at Wilkes-Barre General Hospital told Jesse her claim initially had been denied, she said. Jesse called the customer service number on the back of her insurance card and was told General Hospital had not been a member provider since April 2003.

“If that was correct, then why did they list that hospital as a member provider in informational literature I received in 2007, 2008 and on their Web site a full month after my admission,” Jesse asked.

Her ordeal began in mid-May when she experienced numbness in her left arm and leg that spread to her face, signs of a possible stroke. Under doctor’s orders, she went to the emergency room at Wilkes-Barre General Hospital, which was listed as a member provider in literature Jesse had received from Coventry, her Medicare Advantage provider.

Jesse did not want to wait for the hospital and insurance company to negotiate the bill. The insurance company’s denials that General Hospital was covered put her on alert.

“My entire experience was that of being put on a Lazy Susan and given a spin,” Jesse said. “The important thrust of this whole story needs to be to help Medicare subscribers understand that a Medicare Advantage plan is not necessarily an advantage. Most of these plans limit access to doctors, hospitals and testing facilities. What is more important is that they can change their approved provider list without notice.”

When Jesse filed a formal letter with the insurance company asking them to pay the hospital bill, she was denied.

Undaunted, she appealed the denial, and in late July received a letter from Maximus Federal Services, Victor, N.Y., which is hired by Medicare to review such files and decide if the health plan made the correct decision.

Although Maximus did not ask Jesse for information, she sent them a thick letter. Recently, Jesse received word that she won the appeal and her hospital bills will be paid.

“I had to write just about a college term paper to get it done,” Jesse said. “I’m worried about most of the people in this area. What (the insurance companies) do out-of-hand is deny it – you call the customer service number and they tell you that you did not understand the plan. They look for technicalities to get out of paying bills.

“Somebody’s grandma is not going to be up to this. Where does an 85-year-old lady begin to write an appeal letter? You have to word it right, attach documents.”

Jesse also credits U.S. Rep. Paul Kanjorski, D-Nanticoke, for helping her out. She contacted his office, and his staff made some calls.

Kanjorski acknowledged his office takes care of such problems, but quipped, “We’re not looking for work.

“A lot of times the two are not talking to each other, but over each other,” Kanjorski said. “In this case, (Jesse) had very good records that the company had advertised coverage for that hospital.”

He said his office typically receives calls once or twice a week from people seeking help. One recent call involved a constituent with a life-threatening disease who needed experimental medication. Kanjorski placed a call to a chief executive officer asking for release of the medication, which he got.

“If you think like an egalitarian, it shouldn’t be that way (where a congressman has to get involved.) The reality is, people know we don’t stand alone, but stand with the full force of our federal government. I can call the Food and Drug Administration to get their attention. We make laws, and companies are aware of that. How does a CEO know what calls to take? It’s the same thing if the president calls; I take his calls,” Kanjorski said.

The Pennsylvania Attorney General’s office, the state insurance commission and Medicare did not indicate a high volume of complaints against Coventry, Jesse’s insurer.

Seniors who suspect fraud or abuse related to their Medicare benefit should contact Medicare at 1-800-MEDICARE, and the Senior Medicare Patrol. The Senior Medicare Patrol in Pennsylvania is provided through the Center for Advocacy for the Rights and Interests of the Elderly, and may be reached by calling 800-356-3606 or at www.carie.org/programs/programs_pahcfraud.php.

Lorraine Ryan, public affairs officer for the Centers for Medicare and Medicaid Services, said beneficiaries who experience problems with health plans related to billing, coverage or service issues are advised to first try to resolve the issue with the plan itself through its customer service department, escalating to a higher level person within that company. If the issue is unresolved, Ryan said beneficiaries can call 1-800-MEDICARE to seek assistance or file a complaint.

Also, the local Area Agency on Aging, part of the State Health Insurance Program with a mandate to provide assistance to Medicare beneficiaries, can be reached by calling 1-800-252-1512.

Joe Geibus, staff member at the agency for Luzerne/Wyoming counties, said his office can help seniors get answers on insurance questions.

“I know we could get them resolved. I would tell them somebody’s got to give me an answer and I know I could get it,” Geibus said.

As the re-enrollment period for Medicare plans approaches on Nov. 15, Medicare Part D beneficiaries are encouraged to review their plans.

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