Knoxville woman stuck with $8000 nursing home bill

Confusion over health care coverage leaves Knoxville woman with $8000 bill

Posted:
Justice has supplemental insurance with Blue Cross/Blue Shield of Michigan and when her health is good, she prefers staying with her caregiver. Justice has supplemental insurance with Blue Cross/Blue Shield of Michigan and when her health is good, she prefers staying with her caregiver.
Justice's visit to Hillcrest West, now known as West Hills Health and Rehabilitation. Her supplement insurance did not cover the visit. Justice's visit to Hillcrest West, now known as West Hills Health and Rehabilitation. Her supplement insurance did not cover the visit.
"We go to great lengths to help residents and their powers of attorney to understand that they may be responsible for the cost of their care," said Murphy. "We go to great lengths to help residents and their powers of attorney to understand that they may be responsible for the cost of their care," said Murphy.

By DON DARE
6 On Your Side Consumer Investigator

KNOXVILLE (WATE) - A Knoxville woman was treated at an area nursing home and thought it was covered by her insurance.

But as she and her power of attorney later found out, that wasn't the case.

Medicare is the government's health care insurance program offered to people 65 and older.    

For the those on health care, the decisions and choices they face can be confusing and sometimes overwhelming.

Medicare gives enrollees two very different choices for obtaining health care benefits.

People can choose the traditional Medicare plan to receive benefits up to 80% of the cost, or they may choose a Medicare Advantage Plan, but not both.

Many people elect to stay with the traditional Medicare plan and purchase another private insurance plan, like Blue Cross/Blue Shield. This supplemental plan helps pay co-insurance costs, the other 20% of the bill.

But the system isn't always so clear cut.

With some private insurance programs, enrollees have to know whether the health care facility is within their system's network. If a patient uses a facility outside of the network, they are responsible for paying the other 20%.

Betty Justice, who has multiple sclerosis, recently had surgery and suffers from poor circulation.

Her husband, Glenn, died four years ago. They did not have any children and with her memory failing, there was no one to care for her.

Rodger Herron, the couple's friend from church, agreed to serve as Justice's power of attorney. He watches over her small, fixed, monthly salary.

Justice has supplemental insurance with Blue Cross/Blue Shield of Michigan and when her health is good, she prefers staying with her caregiver.

But over the last year, she's been admitted to Briarcliff Nursing Home in Oak Ridge and Shannondale in Knoxville where her bill was paid in full.

"It's zero. She was there for six weeks and they didn't charge a dime," said Rodger Herron.

Herron said under Justice's health plan, 90 days is the limit for traditional nursing home coverage. That's why she's moved around a bit.

Last fall, she stayed at Hillcrest West, now known as West Hills Health and Rehabilitation.

Herron said he asked whether Justice's supplemental plan was within the network.

"I was told she'd have 90 days of stay there," said Herron. "I would go back every 30 days and check with the social worker and the social worker would say everything is fine."

Herron figured that by the time Justice was at Hillcrest West, Medicare plus her private insurance would cover everything, like at the other homes.

He was wrong.

"They told me everything is fine. It was fine until I got that bill," he said.

Justice received a bill in the mail for $8,300 in the mail.

"It's not right, it's not fair," she said.

Herron filed an appeal for $8,300. It was denied by Justice's insurance company.

Jim Murphy, the president of Hillcrest Health Care, said billing questions shouldn't have been directed at a social worker.

"Our social workers are not involved in the admissions process," Murphy told 6 On Your Side.

He said the company followed proper procedure.

Murphy showed us an admission form that every patient or their powers of attorney sign. One section addresses private health insurance, which states it's the responsibility of the resident.

"We're going to help them certify their coverage, we're going to explain to them just how we work, we're going to go through all the paperwork that is necessary," Murphy said. "However, it's important to know claims may be denied. We go to great lengths to help residents, their powers of attorney to understand that they may be responsible for the cost of their care."
 
Cindy Troyer is an advocate for patients as the ombudsman at the East Tennessee Human Resource Agency (ETHRA).  

She said billing issues, like the one faced by Justice, come across her desk frequently.

Troyer said verifying coverage needs to be established on the front end.

"I think it would be good to talk with the business office manager at the nursing home or the admissions coordinator who keeps a running list of which contracts the facility operates under and also to check the insurance company itself" said Troyer.

Herron has paid Betty's $8,300 bill. He said the next time he'll go beyond the social worker and ask more questions to the right people.

Health care providers say the reimbursement process is complicated, is sometimes beyond their control and often changes.  

So the important thing for patients to remember is to check and double check with a home's admissions office and with the provider.


If you have a consumer issue, call the 6 On Your Side Hotline at 865-633-5974 or email ddare@wate.com.

Powered by WorldNow
All content © Copyright 2000 - 2014 WorldNow and WATE. All Rights Reserved.
For more information on this site, please read our Privacy Policy and Terms of Service.