Navigating the medical systems for seniors

[Case]

My mother was recently on a trip and had sudden bloody diarrhea and extreme pain.  She went to the ER who put her on strong painkillers and antibiotics.  However, despite many efforts has not been able to get an endoscopy scheduled for many weeks out.  The blood is subsiding but she has painful waves of lower intestinal cramps.  Basically you need an endoscopy to diagnose further.

Part of the problem is the time of year.  But a big problem is how medicare vs insurance works for her.  She has to go thru medicare forst( and i guess use it up) and then go thru her insurance.  Medicare i believe requires her to be treated at a hospital and so she cant get a faster endoscopy at a non-hospital office.  She has gone back to the ER, and they tell her to suck it up and deal with the pain for a few weeks, until the endoscopy.  This seems insane to me.  She is almost bedridden. 

Any ideas on how to accelerate her treatment?  One option we are considering is to pay cash for the endoscopy in order to get it faster, and then hope insurance will cover after the fact.

[Cassie]

I am a year away from Medicare but this sounds scary Your poor Mom.

[Case]

My mother was recently on a trip and had sudden bloody diarrhea and extreme pain.  She went to the ER who put her on strong painkillers and antibiotics.  However, despite many efforts has not been able to get an endoscopy scheduled for many weeks out.  The blood is subsiding but she has painful waves of lower intestinal cramps.  Basically you need an endoscopy to diagnose further.

Part of the problem is the time of year.  But a big problem is how medicare vs insurance works for her.  She has to go thru medicare forst( and i guess use it up) and then go thru her insurance.  Medicare i believe requires her to be treated at a hospital and so she cant get a faster endoscopy at a non-hospital office.  She has gone back to the ER, and they tell her to suck it up and deal with the pain for a few weeks, until the endoscopy.  This seems insane to me.  She is almost bedridden. 

Any ideas on how to accelerate her treatment?  One option we are considering is to pay cash for the endoscopy in order to get it faster, and then hope insurance will cover after the fact.

Correction: colonoscopy not endoscopy.

[Another Reader]

None of this makes any sense.  There are multiple parts of Medicare plus Medicare supplement policies.  Medicare Part A is for hospitalization.  Part B is for doctor bills, and you pay a monthly premium to Medicare for it.  Part B pays 80 percent of most doctor bills.  There is also a small deductible.  You can opt out of Part B, but unless you have coverage from your company or some other source, you will pay a penalty if and when you sign up.  You should make sure your mother has either Part B or equivalent coverage from an employer or a spouse.

The other 20 percent of the medical bills are her responsibility.  Most people purchase a supplement plan to cover those charges.  Supplements are sold by private insurance companies.

Part D is drug coverage.  Those policies cover drugs dispensed by pharmacies. The plans are sold by private insurance companies.

Finally, there is Medicare Advantage.  Everything listed above is covered by a single company, and the insured is no longer covered by Medicare.  These policies have deductibles and copays.

Your first job is to find out which policies she currently has.  If she has an Advantage policy, she is at the mercy of the insurance company for determining what doctor network she can use and if/when she gets tests.  You, she, and her doctor need to convince the insurance company to approve and expedite the colonoscopy.  If she has regular Medicare, Part B, and a supplement policy, she can see any doctor that takes Medicare.  Can't get the first doctor to get a colonoscopy scheduled immediately?  Move on to another doctor.

Paying cash and getting reimbursed is generally not an option with Advantage policies. 

You or she need to look at the policy and discuss the procedure with her doctor and the insurance company.  If the insurance company drags its' heels, call your state department of insurance and find out how to file a complaint.

[ETBen]

It might not be that Medicare requires it to be at a hospital (actually I know this is the case). It’s more likely that A) the doc feels she’s not healthy enough to do this at an ambulatory center or B) her GI doc does everything at the hospital so he doesn’t want to schedule elsewhere or C) as another posted, she has Medicare Advantage and they don’t have a network that includes more providers and locations.

[freya]

This sounds like a 3 way communication problem & game of telephone between the physicians, your mother, and you.  Insurance is almost certainly not the issue.

The question here is whether the colonoscopy is needed urgently.  If the diarrhea is "subsiding", it may be better to allow it to resolve before doing the procedure, and that's the reason for the delay.   It may not even be needed at all, as these symptoms could easily be due to an infectious disease that will resolve on its own, e.g. shigella.  If she's in pain in the meantime, that needs to be addressed.  If the pain has worsened, that is something to tell the doctors about.  It should prompt a reassessment and possibly change in plan.

Generally, if your mother is having trouble understanding the situation, it's a good idea for the family to choose ONE spokesperson, and have that person communicate directly with the doctor(s).   Getting this right will help tremendously in what I am sure is a very stressful situation.  Getting your mother back home will probably also help, as it's best for her to be under the care of physicians who she knows, and who know her history.

[Case]

This sounds like a 3 way communication problem & game of telephone between the physicians, your mother, and you.  Insurance is almost certainly not the issue.

The question here is whether the colonoscopy is needed urgently.  If the diarrhea is "subsiding", it may be better to allow it to resolve before doing the procedure, and that's the reason for the delay.   It may not even be needed at all, as these symptoms could easily be due to an infectious disease that will resolve on its own, e.g. shigella.  If she's in pain in the meantime, that needs to be addressed.  If the pain has worsened, that is something to tell the doctors about.  It should prompt a reassessment and possibly change in plan.

Generally, if your mother is having trouble understanding the situation, it's a good idea for the family to choose ONE spokesperson, and have that person communicate directly with the doctor(s).   Getting this right will help tremendously in what I am sure is a very stressful situation.  Getting your mother back home will probably also help, as it's best for her to be under the care of physicians who she knows, and who know her history.

Its hard to say without me being there myself to talk to the doctors (i live some distance away).  There seems to be some amount of poor communication from the doctors and their staff.  They didnt explain anything to her.  The ER she initially went to gave her a CT scan and has since lost the results; this is the Tulane ER... i would think such a fuck up is embarrassing.  Will be interesting if they try to bill for it.

No real diagnosis was made yet... they generically called it colitis. 

She is back home, and her local gastroenterologist couldnt get her an appointment until several weeks out.  This was after a lot of pushing.  On the one hand maybe the office is overburdened... on the other hand, the office has 16 doctors.  She also lost some sort of priority status with the doctor because she hasnt been there in a few years, but this is due to only getting colonoscopy every 5 years at her current age.

Anyways, this is a wakeup call that i need to begin understanding and monitoring my parents insurance and health more closely.

[MayDay]

I don't know your mother's age from your posts, and if someone is going with her, but I would not trust much of what she is reporting to you if she is going alone- when you are sick and not feeling well, regardless of age, you don't tend to do a great job of keeping track of these things.  She really needs someone to attend appointments with her and keep track of all the details, and keep a good record of who is saying what, when. 

Sounds like that person can't be you- so who can it be? 

My boss is dealing with this stuff right now (elderly mother is sick with stomach issues, lots of pain, getting the run around, lots of delay in getting appointments).  At first her elderly father was attending all appointments, but he wasn't doing a great job of managing all the details.  Now children are attending appointments, but due to the nature of them all still having FT jobs and lives of their own, they are taking turns, which adds another layer of miscommunication to the whole thing.  They are seeing specialists in multiple hospital networks, so all the electronic charts are not talking. 

If possible, can you do everything going forward in the same hospital system?  That seems to be hugely helpful. 

None of this stuff is easy. 

[freya]

Definitely agree with the "not easy" description!

If there's no family member nearby who can be the spokesperson and your mother is having difficulty coping with the situation, a geriatric care manager may be appropriate to bring in.  However, you can be a pretty good spokesperson if you're willing to make some phone calls.

I've thought about getting into a boutique primary care practice before hitting Medicare age, precisely because of scenarios like this.