Medicare Denies Our Legitimate Claim

Two years ago my 90 year old husband underwent the amputation of his last remaining leg. A couple of days after his operation, the hospital sent him, on doctors orders, to a rehab for recovery. We asked if Medicare covered the ride and were told 'yes'. The first rehab was not equipped to handle his needs and they sent him to another rehab by ambulance, where he stayed for his rehab. Again we were told the ride was covered by Medicare. We had no choice in either case as to what mode of transfer was best and we signed no ABN or anything saying we would pay. We weren't consulted about either ride, or told there might me a chance we would have to pay for it, we just did what was ordered. In both instances my husband could not walk or sit up in a chair and was heavily medicated.
Well, Noridian, Medicare's contractor, denied both claims. I took the first one to the hospital social worker who had originally called for the ambulance and she said the ambulance company must have put down the wrong code or something. She said she would take care of it, but we got the bill again. We did the same thing with the denial of the second ride and took it back to the nursing home. They also said it was a mistake and they would take care of it. We hear nothing for so long, we actually believe they've done what they said they would do.
Long story short, it turns out the ambulance company appealed but failed to do it in the proper time allotted, so it was denied again. We tried to get a new review, and were plainly told by Noridian, "no, we already reviewed it" The ambulance company, for the life of them, could not understand why Noridian denied the claim in the first place, because my husband met every criteria Medicare requires and they felt sure they sent in everything they should have. I called my Congressman's office here in on it and they could not understand why Noridian was denying it either. They made some inquiries but hit the same brick wall we did with Noridian. By now we have recieved a denial for the second ride and the ambulance company has sent it to a collector who just informed us it is going on my husband's credit record.
All our paper work says we can call 1-800-Medicare if we have questions, so I called them. 1-800-Medicare kept me on the phone for two hours asking me to please not hang up while they tried to get to the bottom of it all. Two supervisors there told me there was no way we should have to pay this claim. They both said that Noridian should never have denied it in the first place, and that the ambulance should be handling this, not us. The highest ranking one I talked to read me an email she was sending to Noridian and she was also asking them to call us. A lot of good that did. We never received a call and nothing changed. I tried to call and talk to either of those supervisors again, but guess what? You get a different person in a different state every time you call 1-800 Medicare and they have no way of connecting you to the same person you had before, even if you know their names, which I did. So when I called back, I had to talk with a different person and explain it all over again. This advisor told me that if my husband was not told he would have to pay for the service and did not sign any ABN that would have let him know he might have to pay, then he could not be held liable. I wish! That's the way it should be. She was dreaming!
The original reason Noridian gave us for the first ride, was that the ambulance company didn't supply enough info. But now, Noridian is saying that both rides are denied because he could have been sent by some other means. Why wasn't that the reason the first time it was denied? Everyone we've talked with, Medicare advisors, the doctors, the hospital, the congressmans office and the CMS representative she talked to, the nursing homes, even the ambulance companies that are billing us, all say my husband's claims never should have been denied. He couldn't get out of bed, he couldn't walk or sit in a wheelchair. He was drowsy with percoset and didn't even have anything to do with calling the ambulance, the hospital and nursing home did, but Noridian wants to make us pay. I have his medical records, and a letter from his surgeon testifying that ambulance was the only safe way to transport him, Medicare's own manual and all we see on their own websites say that my husband met every criteria required be them. But Noridian says no.
We have been appealing for two years and just finished what they call an 'Independent Review'. Problem is, the company that reviews the claim works for them. That's not independent. Now, the reasons for denial have changed again, saying he should have gone by stretcher van instead of ambulance. Their exact words: "The patient was not in any pain, except when being moved and could have been transported by stretcher van. Therefore the need for ambulance transport has not been established." Where is that found in our manual or even in our policy? I've asked after every denial, for copies of whatever statutes, rules, or regulations that they used to come to their decisions, and I've never received them. I would say, if the doctor ordered it and said he had to have it, it's been established. They tell us these denial decisions are based on opinions of Noridian's registered nurse and a registered nurse from the independent review. They are not doctors, and have never met my husband and were not there after his operation, but we are supposed to believe these Noridian-paid nurses are able to give an unbiased and educated opinion which totally overrides and disqualifies the decisions and highly-educated opinions of a very experienced and renowned orthopedic surgeon who was actually there performing the operation, and all the other medical professionals at his side. Incredible!
The way I understand it, Noridian has an incentive program going which pays their employees huge bucks for denying claims. You can read about it in articles on the Internet, and even find the incentive program itself, Online. Of course, the claims they deny are not supposed to be legitimate claims, but with huge incentive programs like that, I can't believe they don't use every little tool and technicality they can. I am also having a very hard time believing they don't target the disabled and elderly. My husband would never be able to fight this at all. Long holds on the phone, button pushing for this option or that, making copies, gathering evidence and records, and all the other hoops they make you jump through just to get to the appeals stage. They know darn well these fragile beings will never make it and that they will pay- up for fear of prosecution.
Now to top it all off, guess what I've discovered? Stretcher vans are illegal in our state! When I told Noridian this they told me that's not their problem. Evidently, they are in a battle with our state over whether or not stretcher vans are safe, and they've made my 92 year-old husband their whipping boy. The stress of all this is killing us. These bills are now up to $1500 or more. Now, this 92 year-old double-amputee with a bad heart is expected to arrange for an ALJ, Administrative Law Judge to listen to his plight. Why is there no limit of liability for us? We signed nothing and were told nothing. Why isn't this a battle between those who actually signed a dotted line? Why isn't this being duked out by the person who called for the wrong mode of transport or the person who failed to put down enough info, or the ambulance company who failed to appeal in time? Why is this disabled 92 year-old having to do all the work? My husband is being denied his benefits to Medicare due to someone else's mistake. Benefits he paid for and is still paying for. How can we get justice?