WASHINGTON -- Frail, elderly Medicare beneficiaries with severe illnesses are being improperly denied coverage for home health services that they are entitled to receive, U.S. judges have ruled in thousands of recent cases around the country.
Government data indicate that 39 percent of the people who contested the denial of such benefits -- 18,500 of 48,000 -- won coverage at the first level of review. Of those who pressed their claims, 81 percent prevailed on appeal, or 6,300 of the 7,800 cases.
Medicare officials typically contend that the patients are in stable condition, are not homebound and so do not need the home care ordered by their doctors.
After Medicare refuses to pay, patients sometimes find that they are responsible for bills amounting to tens of thousands of dollars for hundreds of visits by nurses and home health aides.
But judges have rejected the Clinton administration's arguments in case after case involving patients who are chronically ill, disabled, blind or confined to wheelchairs, or are suffering from such ailments as Alzheimer's disease, Parkinson's disease and multiple sclerosis.
To qualify for home health services, Medicare beneficiaries must be "confined to the home."
In many cases, patients say, they need home care to live independently and to stay out of nursing homes -- just to get out of bed.
But if they have any degree of independence, Medicare often denies their claims for home health services, the very services that allow them to attain a measure of independence.
Judith Stein, director of the Center for Medicare Advocacy in Willimantic, Conn., said her organization had won scores of cases challenging Medicare's denial of home care to the chronically ill.
"These decisions should be a signal to the agency that it has a problem," said Stein, who received a certificate of merit from the government for "outstanding services to Medicare beneficiaries" last year.
Medicare officials deny that there is a pervasive problem and say that individual beneficiaries may appeal if they believe they have been improperly denied home care services.
Appeals normally take more than a year. The resulting decisions usually apply only to services provided in the past; they do not necessarily guarantee coverage in the future.
People who successfully appealed in the past are being denied again. One such patient, Rosalie Berkowitz, a 67-year-old with multiple sclerosis, lost her home care benefits in 1988, regained coverage through a lawsuit and is now appealing a second decision to terminate her benefits.
