Your Right to Appeal
The Savvy Senior
By Robert Goodman, MSW

Being a good health care consumer means knowing your rights and advocating for yourself. Whether you are applying for or currently receiving services you have the right to appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare plan, Social Security, or any government agency. Different programs and services have different procedures for appeals. The time allowed for appeals also varies.  HMO patients also have the right to appeal adverse decisions.

Hospital patients have the right to appropriate care and appropriate discharges. A person cannot be discharged into an unsafe environment, such as being sent home where they cannot take care of themselves or no one is available to care for them.

A Medicare beneficiary has the right to appeal a hospital discharge if he or she feels too sick to leave. A hospital will provide “An Important Message from Medicare,” which explains how to appeal the discharge. Medicare beneficiaries can call Florida Medical Quality Assurance, Inc (FMQAI) at 800-844-8754 for an appeal. FMQAI staff members will look at the medical record to see if the beneficiary should stay in the hospital. The beneficiary will be informed of the decision. The Medicare beneficiary does not have to leave the hospital. The Medicare beneficiary does not have to pay for the extra days in the hospital while FMQAI staff members review the medical record.

A Medicare beneficiary has the right to appeal a discharge if he or she does not agree with the discontinuation of skilled services (skilled nursing care, hospice, home health care). The beneficiary must be given a letter with the planned discharge date explaining how to appeal the discharge. Once the beneficiary receives the letter, he or she can call FMQAI at 866-800-8768. An FMQAI physician will look at the medical record to see if the services should continue. The Medicare beneficiary will be informed of the decision.

If a Medicare beneficiary is in an HMO, he or she has some additional Medicare rights. If the beneficiary feels he or she cannot get the needed care, he or she has the right to appeal to the HMO. The Medicare beneficiary can appeal things like denials for: referrals to a specialist, approval for tests (like x-rays or blood tests), or payment of a bill.

The HMO has information about how to start the appeal process. A Medicare beneficiary who feels he or she may get worse by waiting too long can ask for an expedited appeal. This means the HMO must make a decision about the appeal within three calendar days. A Medicare beneficiary who needs an expedited appeal must be sure to ask for it.

If a Medicare beneficiary has a concern or is not satisfied with the quality of care received, he or she can call the FMQAI Florida Medicare Beneficiary Complaints Helpline at 800-844-0795. You may also download a quality of care complaint form English or Spanish to complete and fax to 813- 354-0737, or mail to: FMQAI, 5201 West Kennedy Boulevard, Suite 900, Tampa, Florida 33609, Attention: Beneficiary Complaints.

The above information is from www.fmqai.com and www.medicare.gov. For more information on your right to appeal a Medicare related decision call 800.MEDICARE (633-4227).

Here are ten steps to help you become an effective self-advocate:

1. Believe in yourself
2. Realize you have rights
3. Discuss your concerns with your service provider
4. Get the facts in writing
5. Use the chain of command to solve a problem-ask to speak to a supervisor if an issue wasn’t resolved to your satisfaction
6. Know your appeal rights if services are denied
7. Be assertive and persistent, not aggressive
8. Outline your concerns and be a good listener
9. Ask for help from other agencies
10. Follow-up. Be sure you’re getting the service that meets your

needs…and say thank you

Are You or a Neighbor Self-Neglecting?
The Savvy Senior
By Robert Goodman, MSW

There are many stories in Century Village, and you hear them all while riding the buses. I have heard stories of people laying on the floor for four days and not allowing anyone to call 911, stories about residents who cannot take care of themselves and have no food in their home who will not let anyone in to help, people who have money and won’t use it to care for themselves. One who does this or allows it to happen is guilty of neglect.

As a geriatric social worker, I want to help all these people, but realize I cannot save the world. But each one of us has a responsibility to help our neighbors as best we can when they are in need.

Self-neglect is a general term used to describe a vulnerable adult living in a way that puts his or her health, safety, or well-being at risk. The state’s definition of neglect is “Unexplained or unexpected deterioration of health, personal care or living situation. This includes inadequate food, clothing, and/or shelter.” Self-neglect is defined as “when individuals fail to provide themselves with whatever is necessary to prevent physical or emotional harm or pain.” Some people get to a point when they become a danger to themselves or others. These are serious situations and need to be dealt with.

Vulnerable adults who neglect themselves are unwilling or unable to do needed self-care.  This can include such things as:

• Not eating enough food to the point of malnourishment.
• Wearing clothes that are filthy, torn, or not suited for the weather.
• Living in filthy, unsanitary, or hazardous conditions.
• Not getting needed medical care.

There are some common characteristics of adults who neglect themselves.  He/ or she is more likely to:

• Live alone.
• Be female (possibly because more women than men live alone).
• Be depressed and/or increasingly confused.
• Be frail and elderly.
• Have alcohol and drug problems.
• Have a history of poor personal hygiene or living conditions.

Signs to look for:

The Home

• Not enough food, water, heat.
• Garbage and rotting food in refrigerator
• Filth or bad odors, hazardous, unsafe, or unclean living conditions or fire hazards.
• Major repairs are needed and not done.
• Human or animal feces.
• Hoarding: nothing is thrown away, stacks of papers, magazines.
• Animal or insect infestation.

The Person

• Poor personal hygiene (dirty hair, nails, skin).
• Smells of feces or urine.
• Unclothed, or improperly dressed for weather.
• Skin rashes or bed sores (pressure ulcers).
• Dehydrated, malnourished or weight loss.
• Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or a commode.
• Increased dementia, confusion, disorientation.
• Unexpected or unexplained worsening of health or living conditions.
• Spending too much time alone or isolated from former activities.
• Lack of interest or concern about life.

• Untreated medical conditions.  Failure to take medications or go to doctor or dentist.

• Self-destructive behaviors or significant behavior changes.
• Hallucinations, delusions.
• Misusing drugs or alcohol.

A self-neglecting older adult may have the capacity to make decisions, but his/her ability to identify and remove oneself from a harmful situation may be limited or compromised.

There are many possible reasons why a formerly meticulous person may have changed so drastically. Some of the more common reasons include:

• Medications
• Cognitive impairments
• Depression
• Alcohol or drug abuse
• Isolation

If you know of or suspect someone is a victim of abuse or neglect call 1-800-ABUSE (2873). You can remain anonymous. When calling to report abuse or neglect give the person’s name, address, family contact information if available, and describe the situation. For general information on services for seniors call the Elder Helpline at 1-866-684-5885 or 211.

(Sources: Palm Beach County Area Agency on Aging, State of Washington Department of Human Services, AARP)

Resources on Elder Abuse and Neglect:

Foundation for Healthy Aging

www.healthyaging.org

National Institute of Health Medline

www.nlm.nih.gov/medlineplus/elderabuse.html

National Committee for the Prevention of Elder Abuse

www.preventelderabuse.org

National Center on Elder Abuse

www.ncea.aoa.gov

Prevent Elder Abuse and Neglect
The Savvy Senior
By Robert Goodman, MSW

April is Elder Abuse month. Elder abuse and neglect are a major issue in Florida where so many seniors retire. Elder abuse comes in many forms: physical, psychological, financial, and sexual. Many older adults cannot take of themselves due to frailty or dementia and either self-neglect or are neglected or exploited by others. Tens of thousands of seniors are abusing each year. The most vulnerable seniors are white women 77 years of age or older.

You can help stop abuse and neglect of the elderly by understanding what abuse and neglect are and by learning the signs. Reporting elder abuse and neglect is an obligation for all Florida residents.

Physical abuse includes any physical contact with an older adult that results in a physical injury. Self-neglect is often indicated by a person’s inability to care for themselves. Neglect by others may result in malnutrition, dehydration, or a failure to get help or services for a frail older person. Psychological abuse is indicated when a person is being harassed, berated, put down, and made to feel bad about themselves. Financial exploitation involves the improper use of someone’s funds, property, or assets.

If you believe someone is being abused, neglected, exploited by someone else, neglecting themselves you have a legal obligation and moral responsibility to call the state abuse hotline: 1-800-96ABUSE or 1-800-962-2873 and report the situation. You can report anonymously.

A new ordinance passed in Palm Beach County now requires any home health aide to be licensed and fingerprinted. This law was passed in an effort to combat abuse in our county. For information contact the Department of Consumer Affairs at 1-888-852-7362.

Elder Abuse and Neglect Resource Contacts:

Elder Helpline

1-800-96ELDER

Fraud Hotline

1-800-378-0445

Statewide Senior Legal Helpline

1-888-895-7873

Consumer Services

800-435-7352

Financial Services

1-800-342-2762

National Fraud Information Center

1-800-876-7060

Resources on Elder Abuse and Neglect:

Foundation for Healthy Aging

www.healthyaging.org

National Institute of Health Medline

www.nlm.nih.gov/medlineplus/elderabuse.html

National Committee for the Prevention of Elder Abuse

www.preventelderabuse.org

National Center on Elder Abuse

www.ncea.aoa.gov