i dont know the answers to your questions about if the alj can overule medicaid guidelines but i just wanted to say that i think you did a great job and gave it the good fight. You should have directly asked the insurance people about wether they ever received the paperwork from the orthotics place for authorization and reminded them that they were under oath.ha! They are all full of doggy diamonds. Did Alan get another pair of shoes paid for by the insurance company? Its not clear at the end of your post it seems he got another pair of shoes but i might be misinterpreting. I wish you luck and hope he gets the orthotics. This is where our "ADVOCACY" organizations should be involved in the fight.

Thanks for the nice words.
Yes (read the very last line of my original post.
this is what I said:

"So again, Alan HAS the shoes with the orthotics. His HMO only paid for Shoes, but refuse to pay for othotics. "

What this means is that Alan got a new pair of shoes in 2009, and his HMO paid for the shoes, but they refuse to pay for the Orthotics that were fitted to go INSIDE of the shoes.

In 2008, his HMO paid for BOTH shoes and orthotics. But in 2009, they only paid for shoes.

Then they said they never pay for shoes and orthotics unless a person is diabetic or unless the orthotics are fitted with a brace.

That's when I politely interrupted and said ""But oh, you DID INDEED pay for the shoes and orthos in 2008 and you paid for the shoes in 2009" and the Judge then said: "why did you pay for these items?" and the girl said "Well, to tell you the truth Your Honor, I have no idea why we paid for these items, this was a mistake, and we are not going to ask to recover that money".

Can you imagine this? They first indicate that they never pay for these things and then they admit they paid and made a mistake.

I think Alan has a fighting chance. And the Judge asked them if they ever received a pre-authorization about the orthotics and they lied and said: "no we received nothing from the shoe company"

Oh Really?? then how come Alan got SHOES!!!! Because the submission was made at the same time, both shoes and orthos were molded at the same time.

This whole thing makes me nervous.

I know insurance companies try to get out of paying for stuff, I know this. But the best was when the Judge said "Let me get this straight, Alan has neuropathy, you acknowledge that Alan has neuropathy, he has the same condition as a diabetic but you won't pay for the shoes because he's NOT A DIABETIC?? Even the judge sounded skeptical.

But the other side admitted this was so.

So how does one change the medicare guidelines anyway. I'm up for it.

Maybe that judge might think "oh my goodness, what if my mother or father gets neuropathy, but isn't a diabetic, you mean medicare won't cover shoes for them?

It's something to think about, no??

We shall see. And I'll update you all.

This will be a MAJOR discussion at the next Neuropathy Support group meeting.

Melody

--you did an excellent job on this, Mel.

Basically, as far as I can see, you caught them in a mistake at the very least and in a deceptive practive at worst.

The question is how far the judge's authority actually extends in these cases--and I admit I have no idea what the political considerations are. I couldn't even speculate whether the judge is compelled to follow the regulations to the letter, can bend them in certain cases, or is independent (and ornery) enough to want to make an example/teach a lesson to the other side and make them pay for their incompetence and/or deceit.

But Echoes is right; this is PRECISELY the type of thing that an advocacy organization should be lobbying abround, and bringing it up at the next neuropathy support meeting can only help. Wonder if you could get some of the administrators from the Association there . . .

Forget about getting the Administrators fromthe Associatio there.

That's the first thing I did when Alan initially got denied. I called them, I emailed them. I got a very polite email response indicating that they don't do advocacy (I initially asked them to be a witness at the hearing (over the phone), or could they write a letter or SOMETHING. The answer was, regretfully NO, Then I contacted ANOTHER Neuropathy Organization, and asked the same thing. Same response.

So no help in THAT Department.

I AM WONDERING if the ACLU would get involved, (in case we get turned down again).

I asked Alan, "Is this as far as we can go, (the hearing with the ALJ I mean)? And Alan said "No, the next step is to go to an actual Court, but I'm not up to that". So I said 'So this is it?" And he said "I guess so".

Alan is on Social Security, and the foot company (A very very nice Foot Orthotic Company) knows this and probably won't pursue payment.

Immediately after I got off the phone with the ALJ, I phoned the Foot company and got on the phone with their billing department (we're old phone friends because of all these shenigans). I had her laughing on the other end. She said "You know, you should go to Court when I go to Court".

I told her "I'm just letting you know that we did do a good job of why your company should get paid, that my HMO did pay previously".

She said "Yeah, I know, but HMO's lie all the time and the judge's know this"

I didn't know that.

So we fought the good fight, and in a few weeks, we'll find out if we won the good fight.

Oh, on another note, I AM ENTITLED TO A PAIR OF SHOES EACH YEAR because I'M A DIABETIC RIGHT?

Wrong!! Same HMO as Alan.

Seems that when my podiatrist put in my prescription for my shoes (as he does every year), well this time, they only will pay $88.00 and that' NOT ENOUGH TO COVER THE COST OF THE SHOES. So we are finding out if my doctor's office will accept this payment. He is part of a practice and lately he said the HMO's only pay something like $40 for a pair of shoes. (I must be lucky, they paid $88.00 for mine).

I called up the girl who handles all the insurance (at my podiatrist, I mean). I asked her "If your office got paid the $88.00 and you are not satisifed with that amount, what happens next?"

Her reply was "Oh, we refund the money to the insurance company". This happens all the time.

So as soon as I heard that, I went to Payless and got a $20.00 pair of nice white sneakers (with a wide toe box).

That will work fine for now, but I guess I'm facing MY OWN FIGHT for my own pair of shoes.

But you see, I'm not complaining. I can go into any shoe store and buy a pair of shoes. Alan CANNOT DO THIS.

So if anyone knows who I can write to to have them re-think their medicare guidelines rule, let me know okay?

Oh, and this is interesting, when I was on the phone with the Foot Company representative I asked her if the judge has the discretion to side with us against the HMO, or if he had to follow the medicare guidelines as well.

Her reply: "Of course he has discretion, HE'S THE JUDGE, if he didn't have discretion, there would have been no hearing over the phone".

So she thinks we just might have a shot.

time will tell

lol

Melody

i can see a neuropathy organization not wanting to come to a specific hearing because of lack of time or manpower but you would think that they could write up a standard brief that a person could submit as to why some non diabetic PNers have the medical necessity of orthotics and shoes. That California organization talks a good ball game but that appears to be all they do. Both organizations are absolutely useless. They should be working on getting the medicare rules changed at the federal level. What is it exactly that they do?

I agree, so it has to be UP TO US to do DO THE WRITING AND EMAILING.

Anyone know who writes the medicare guidelines and who I can write to?

Thanks much

Melody

Found these two sites from Medicare concerning shoes, etc. Interesting.

http://www.medicare.com/equipment-an...-footwear.html

http://www.medicare.com/equipment-an...tic-shoes.html

Government writes the rules???

Melody,

Have you looked into this medicare advocacy org?
http://www.medicarerights.org/

May be worth a shot.