Today I received a phone call from somebody claiming to be an agent for Homeland Security. He threatened me with prosecution, if I do not "cease and desist" from contacting Health and Human Services.

The following is an email that I sent to Bette Weisberg at Health and Humana Services on January 9, 2005. It is a rebuttal to statements that she has written to me. I offered her the opportunity to comment about the matter. I have decided to rescind my offfer, after receiving the phone call from "Homeland Security".

For the record:

Dear Ms. Weisberg:

Do you have any comments to make about Fact Vs. Weisberg before it is published online?

Please respond by January 14, 2005.

Sincerely,
John H. Olsen

Fact Vs. Weisberg

Rebuttal to Weisberg’s August 6, 2004 Letter



Weisberg: “In regard to your complaint that Mr. Joseph Pich did not receive "acute rehabilitation". Medicare does not define rehabilitation services as "acute" or "sub-acute".”



Fact: Regardless of how Medicare defines rehabilitation, there is a difference in the real world between “acute” and “sub-acute” rehabilitation. For one, “acute” rehabilitation costs more than “sub-acute”. The difference is well documented and easy to verify.





Weisberg: “It is our understanding that Mr. Pich was referred for a rehabilitation evaluation while at Lutheran General Hospital. The purpose of the evaluation was to determine if his condition warranted rehabilitation and, if so, the subsequent course of treatment. The rehabilitation services, which the evaluation deemed appropriate, were approved.”



Fact: There was never any doubt that Mr. Pich would need physical rehabilitation after his surgery. Mr. Pich was evaluated by 6W because Dr. Rajan Raj, Mr. Pich’s surgeon, requested that Mr. Pich be given rehabilitation at Lutheran General Hospital’s 6W acute rehabilitation facility. After the evaluation, 6W was notified that Humana would not pay for rehabilitation at 6W, because it was “out of network”. This information is available via 6W records. Mr. Pich was sent to Warren-Barr Pavilion because Humana would only pay for “sub-acute” rehabilitation. Humana did not notify us in any manner of their denial, effectively denying us the right to appeal this organization determination.



Weisberg: “You were given a choice of several facilities where Mr. Pich could receive these rehabilitation services. You selected Warren Barr- Pavilion and he received the approved services at that facility. No services were denied. Hence, there was no written denial notice or clinical rationale/criteria to provide to you.”



Fact: I was given the choice of several facilities where Mr. Pich could receive rehabilitation services, but I was not told that he had been denied access to 6W, because “insurance denied – out of network”. I was told that his evaluation determined that he was not a candidate for “acute” rehabilitation. Based on this false information, I did not appeal, because this is not appealable. Humana and Advocate effectively denied us the right to appeal by misleading us as to the reason why he was not accepted at 6W.





Weisberg: “Your understanding that services were denied because Lutheran General Hospital is out of Humana's network is inaccurate. Again, no services were denied. Moreover, Lutheran General Hospital was and continues to be in Humana's network.”



Fact: I did not say that Lutheran General Hospital was not Mr. Pich’s network hospital. Hospital documents show that Humana determined that as of June 2003, Lutheran General Hospital’s acute rehabilitation facility, 6W, was “out of network”. Lutheran General Hospital ceased being the Pich’s network hospital when they were banished from Advocate’s network.



Weisberg: “As you subsequently requested, Advocate Health Care sent you the criteria for skilled nursing and rehabilitation services on July 19, 2004. These criteria relate to Mr. Pich's discontinuation of skilled nursing services at Warren Barr Pavilion; (also see first bullet on page 2).”



Fact: I never requested that Advocate Health Care send me the criteria for skilled nursing and rehabilitation services. Per Chapter 13, Section 40.2.2, of the Medicare Managed Care Manual, I have repeatedly asked Advocate and Humana to send us the specific reasons, for their denials of various benefits of the Pichs, that take into account the Pich’s presenting medical condition and disabilities. The material that Ms. Weisberg refers to could apply to anybody, and had nothing to do exclusively to the Pichs. Advocate and Humana refuse to provide us with the information that we are entitled to, and their refusal is supported by Ms. Weisberg.



Weisberg: “In regard to your complaint concerning Mrs. Constance Pich's quality of care issue, it was appropriately handled as a grievance. As you know per Chapter 13 of the Medicare Managed Care Manual, appealable issues relate to adverse organization determinations. You expressed dissatisfaction with Mrs. Pich's physician, including his medical judgment. There was no adverse organization determination made in this regard so your complaint was subject to the grievance process. Humana sent you an acknowledgment letter on April 23, 2003 and the subsequent resolution letter on May 14, 2003. As you were previously informed, the review findings pertaining to quality of care issues are legally confidential and not subject to disclosure.”



Fact: Per Chapter 13, Sec 30.1.1, and Sec 20.1-20.2.2, Humana,

not the enrollee, is obligated to distinguish between grievances and

appeals. Sometimes a grievance also includes an appealable issue. The

burden is not on the enrollee to make this determination. In Ms. Pich’s

case, on April 23, 2003, I mistakenly filed an appeal with Humana as part of a grievance. I supported my written information verbally in numerous conversations with Humana’s customer service. They should have recognized that my complaint should have been classified as an

appeal as well as a grievance. Per Chapter 13, Sec. 20.3-Procedures for Handling a Grievance, the enrollee is entitled to:



“Prompt, appropriate action, including a full investigation of the complaint if necessary; 5. Notification of investigation results to all concerned parties, consistent with state law; and 6. Procedures for tracking and maintaining records about the receipt and disposition of grievances. Consistent with §170 of this chapter, M+C organizations must disclose grievance data to Medicare beneficiaries upon request. The M+C organizations must be able to log or capture enrollees’ grievances in a centralized location that may be readily accessed.”



Humana’s response to all of our grievances has been the same, and is worthy of being compared to a Marx Brothers routine. First, they acknowledge the grievance in writing, as they are supposed to. They state that they will investigate the grievance, and provide us with a conclusion to the investigation, as they are supposed to. However, the “conclusion” to their “investigation” is always that they will send it to their Quality Management Department for an investigation that is not subject to disclosure. This contradicts Medicare regulations.



Weisberg: • “In regard to Mr. Pich's March 15. 2004 through March 18, 2004 hospitalization at AlexianBrothers Hospital, we referred to this issue in our July 7, 2004 letter. Humana processed your complaint pertaining to the copayment as an appeal. Humana decided to waive the hospital

copayment and informed you of this decision on July 13, 2004.

Your concern that Mr. Pich was treated at Alexian Brothers rather than Lutheran General isexplained by the fact that Mr. Pich was taken by ambulance to Alexian Brothers on anemergency basis. The ambulance was prohibited from going to Lutheran General as Lutheran

General was at capacity and was on official "by-pass" for emergency admissions.”



Fact: Mr. Pich was brought to Alexian because it was the closest hospital. However, once he was stable, and it was determined that he was not in any danger, I requested that he be transferred to Lutheran General Hospital, his network hospital, for any further observation or treatment. This is what is required by Humana. The emergency room physician had no problem with this, and he told me that he just needed an approval from Mr. Pich’s Primary Care Physician. The P.C.P. was not available, so the emergency room physician spoke with the doctor on call, Abkar Khan. Dr. Khan told the emergency room physician that it was O.K. to admit Mr. Pich to Alexian Brothers, in spite of the fact that it was not Mr. Pich’s network hospital. Humana subsequently billed us the co-payment at the out of network rate of 500 dollars per day for the first five days. Mr. Pich was in Alexian for three days. The in network rate is 150 dollars per day for the first five days. I never received notice that Humana waived the co-payment. I had previously filed a complaint against Dr. Khan with the Illinois Department of Regulation. Advocate owns Lutheran General Hospital. Shortly after this incident, Advocate banished the Pichs from the Advocate network.



Weisberg: “In regard to Mr. Pich's discontinuation of skilled nursing services from Warren Barr Pavilion, we intervened and Humana reprocessed the complaint as an appeal. As a result, Mr. Pich's August 22, 2003 through September 19, 2003 skilled stay was paid. (By this time, Mr. Pich was a patient at Lexington Healthcare of Streamwood.) Humana informed you of its decision to pay on March 26, 2004 and we reiterated this information in our July 7, 2004 letter to you.”



Fact: Humana misclassified the August 20, 2003 expedited appeal that I made on Mr. Pich’s behalf, as a grievance. This effectively resulted in Humana denying us the right to appeal. Consequently, Mr. Pich had to stay in another nursing home for three months, at his own expense. Humana and Advocate refuse to provide us with the criteria and rationale, specific to Mr. Pich’s case, that was used in making this determination. Ms. Weisberg supports their refusal. Furthermore, Mr. Pich’s surgeon, Dr. Rajan Raj, told me on numerous occasions, that the rehabilitation that Mr. Pich received at Warren-Barr [sub-acute] was inadequate. He told me that Mr. Pich should have been able to go home after the initial rehabilitation period.





Weisberg: “ In regard to the selection of a new primary care physician, we clarified for you on May 27, 2004 that Mr. and Mrs. Pich had the option to select a primary care physician from other, non-Advocate groups. Their choices were limited to non-Advocate physicians as a result of your contentious approach with their Advocate physicians. This behavior led to a breakdown in the physician-patient relationship. We now understand from the Humana case manager that the relationship with the new primary care physician is satisfactory.”



Fact: In September 2003, I filed complaints with the Illinois Department of Professional Regulation [now known as Department of Financial and Professional Regulation] against Advocate employees David Kushner, M.D. and Abkar Khan, M.D. In April 2004, I was informed via a recorded phone conversation with an Advocate employee, “Mary Jo”, R.N., that Advocate had banished the Pichs from its network because of the complaints that I made.