Does Kafka Work for Medi-Cal?

"Take care of your health; you have no right to neglect it, and thus become a burden to yourself and perhaps to others."

~ William Hall

Here follows another episode in my continuing adventure as unpaid fiduciary agent for a dementia patient dependent upon Medicare and Medical for her custodial care in a residential skilled nursing facility. When we last left our patient, her annual re-evaluation for eligibility for Medical was approved 3 months into the current year. The story of establishing her financial need would be a hilarious saga of plot twists and missed chances if wasn’t such a sad and pathetic tale of bureaucratic bungling and ineptitude.

But that was then. In this latest episode, we have at least two problems. If you count not knowing whether the first two problems are related, we have three problems.

The first issue is what I’ll call a question of “coverage”. Such problems are always heralded by an ominously unexplained “Notice of Action” in which some (usually bad) decision has been made but which is less enlightening about why.  In May, we received a NOA instructing us that because the patient had informed them she was moving to Riverside, her case was being transferred there. Ok, they explained why, but they were wildly wrong. The effect would have been to terminate her coverage at her local facility in September.  We called, we wrote, and we called some more to assure them nobody had ever told them she was moving, that she could not move from bed to toilet, and accordingly that moving from San Diego to Riverside was out of the question. We assumed that the matter would be resolved. Foolishly as it turns out.

When the skilled nursing facility notified us in July the service was still going to terminate in September we called, and after about 20 minutes on hold we explained to James what had happened. He found the file. He found the notice and no information about the patient saying she was moving. He also found our written explanation that no move was contemplated. We believed James when he explained that while he couldn’t personal and directly fix this matter of the move to Riverside, he would e-mail the authority that would. He couldn’t copy us on the e-mail for reasons I can only conclude to be that then I’d have a genuine contact to a real person with real authority and well, we can’t have that can we? But James assured us we would receive a call in a few days assuring us that the case would remain in San Diego. All this was, of course, complete rubbish.

Fool me twice etc. I blame my own naïve faith, coupled with my exhaustion from trying to deal with these people for my failure to follow up when the call never came. That, plus a slight degree of bitterness that this shouldn't be my problem to begin with, but I'm the only adult in the room.

So, on September 11 we received a Notice of Medicare Non-Coverage (NOMNC) from the facility saying the 95-year-old patient’s coverage would end on September 12. Coincidently, this was the same day the patient had returned to the facility from the hospital for her latest bout with COPD, Congestive Heart Failure and an unidentified infection which later proved to be UTI. No reason was given for this action. I have however, formed two theories. One is that the case has been moved to Riverside. The other is that Medical is trying to loosen my already tenuous grasp on sanity in the hopes that I’ll drink myself to death, not appeal their non-coverage decision, and the facility can move the patient’s hospital bed out into the back alley and forget about her. I believe that’s what Medicare would call a win-win since they'd be down two Social Security checks.

This “timely” 24-hour notice included information that if we wanted to appeal we should do so “promptly” by calling our “Quality Improvement Organization (also known as a QIO)”. Needless to say, I quickly made a shaker of vodka martinis with rosewater and lemon syrup before promptly calling the QIO about appealing the NOMNC. Was told by Maria that we’d be contacted by a case manager “in a few days”.  It’s too soon to say whether the QIO measures a few days by Medical time or by actual calendar time.

The next issue is one  of “eligibility” i.e. of proving poverty. Related? Perhaps. Perhaps not.  Although the patient’s financial eligibility for Medical coverage was approved on 2/23/13 for the calendar year 2013, it turns out there is no reason why this issue shouldn't be raised, say every 15 minutes. Here’s how that went down.

We received not one, but two separately mailed notices both dated 9/5/13, both from the same local office of the county Health and Human Services Agency that administers Medical. One was a health insurance questionnaire I’ve seen, completed and returned not less than three times, detailing the patient’s Medicare and Medi-gap insurance coverage. (This matter was fake-resolved last February but because since then Medicare first deducts the monthly premium from her Social Security check then promptly refunds it to her, it clearly wasn't real-resolved.) The other was the equally familiar Verification Checklist  saying we need to “establish/re-establish” eligibility for Medical. Apparently there is no form letter to re-re-re-establish such coverage. We dutifully completed the forms, attached the required bank statements documenting the patient’s poverty. We returned each form in each separate postage-prepaid envelope to the same place.

Let me conclude by saying that I know the social services safety net is pretty tattered. Workers are underfunded and agencies are understaffed. Times are tough and the bureaucrats are more likely to be too busy to read correspondence and forms than they are to be illiterate morons: although the results are the same. I expect that the rate of staff turnover exceeds that of the staff turnover beneath that shade tree outside the Home Depot parking lot. I expect that idealistic workers with a Bachelor’s Degree in some social services major and a desire to do some good for their fellow men experience burnout at rates exceeding that of a cheap cigar. That said, I spent my entire career as a professional bureaucrat and saw some seriously bad shit. But never, not even when contracting with CalTrans, have I experienced such a deficiency of coherent consistent practices combined with such pervasive incompetence.