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M09-1406 dated 9/29/2010
November 16,2010
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certified mail
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Departmental Appeals Board MS 6126
Medicare Appeals Council
330 Independence Ave.
Cohen Building, Room G644
Washington, DC 20201
Attn: Gilde Morrison
Administrative Appeals Judge:
Your Honor:
I was surprised and dismayed when I received your decision. There were two hearing s on this and two ALJ case numbers. Only one is listed. Also there are three suppliers and a decade of claims that were legally filed, protected and appeals done timely and were always part of this appeals case.I'd expected you to remand for another hearing so all the claims would be addressed and all the issues raised. Only all a few of the claim for '1996 and 1997 are listed. Before this went to our honor, I reviewed the file with your staff to make sure that all the issues and documents and 'briefs' were in the file and I was assured that they were.
I am currently being denied life sustaining medical care by Lincare who is now the monopoly supplier in my area as they have not been paid for a decade despite the unprocessed claims pending with Federal workers compensation. Also in the file was extensive documentation to show my attempts to get OWCP judge's remand orders obeyed and claims processed by their Contract bill payer, ACS-Xerox.
Judges orders at the US dept of labor and with Medicare have been brazenly defied.
I agree these are bill approved for life by Federal workers compensation. But they have been pending unprocessed for years. Allegedly by an ' abuse of power' order from a prior Director of Personnel Management for some 'personal reason' not covered by law. Their general counsel had my complete and accurate records a few years ago and they agreed with the bi-weekly posting from the US Dept of Labor to the Medicare computer file. Judge Carter affirmed this in '08 and in '09 but he did not address the three suppliers nor order a basic problem to be corrected. There is supposed to be an initial start date. It was erroneously set for 7/06 rather than 8/1/00. This is blocking current processing at Cigna govt Services who took over as intermidary in '07 and waited until 4/08 for OWCP to input and process the claims which are still unprocessed. Federal Blue Cross Blue shield had started to pay in '99 through '5/02 not aware ( and nether was I that Lincare was actually getting checks for OWCP paid to Health Connections which they bought and Fed Blues paid to Lincare. When Illinois Blues took over in my area they proceeded to want Medicare to pay the bills and even refused to turn over the Medical necessity file to them and my HIPPAA requests go unanswered.
NO More Conditional Payments under Medicare
Did you intend to overturn the Conditional payment law under Medicare which is a 'safety net' that allows Medicare to pay in cases like mine and then collect the monies back from primary payers. Cigna Got services did process this as a 'conditional payment' and Medicare secondary payment recovery services did send a letter out to Federal workers Compensation. If this was a private insurance carrier then they could file with IRS. But how does one 'force' another Federal agency to pay their bills when officials in the agency have thrown away files and are creating 'facts' out f fiction in defiance of their own appellate judges. In my case, in 2/09 they actually remanded the case and ordered the US Dept of labor to ask Me for the 'facts of the case after years of them finding every excuse in the book to not reinstate my monthly wage loss. But, i already had permanent medical benefits but the contractor is still 'offline of the real system and when medical providers and suppliers call they are falsely told the case is closed and some 'third party should pay ' and no one knows anything as they are being told to say something that is not true. I've had 22+ years of no security on my files in any agency since I was injured on 1/10/89. Conditional payments is not medical subrogation. There are some new guidelines to aid MSPRC in collections, but I was told today that they can't be used against a federal agency. How does one file an IRS lien against the US Dept of labor. I was assured by your staff that all this documentation was in the file given to you. its voluminous as its a decade of trying every possible filing to get compliance with judges and the law. ACS personnel even told Lincare in '06 false info that I'd gotten a large settlement that included monies to pay them and they refused service. Rhema came for 2 months and was denied the right to file claims, but extensive proof shows the dates are protected filings. This was with Palmetto GBA. They wanted doctors to leave the diagnosis code off to circumvent OWCP, rather than threat as a conditional payment. Cigna Govt services also made the same requirement and I submitted copies of both Certificates of Medical necessity, completed by my doctor, the one with and the one they had him sign. CMS has chastised doctors for doing this, but they are being required to do so by the intermediaries. It seemed unconsceineable that doctors are being asked to 'police' the CMS business associates ( intermediaries) For a decade no provider or supplier has been allowed to know whom to bill as Medicare Coordination Of Benefits alters the posting in violation of their contract with the US Dept of labor. The system is unsecured and even 1-800- Medicare agents can alter the line up and Fed Blues has called and had it altered as well as CMS Regional office officials. None has access to the official paper files or the facts of the case. When Judge Carter ruled in '08 after River Trust produced the internal documents that are in the file on this appeal, I sent a copy to Medicare Coordination of Benefits thinking that the constant alterations of the official postings would cease. They retaliated even more saying : WE DON'T CARE WHAT A MEDICARE JUDGE SAYS. Currently, CMS regional office officials have done the same thing with your decision on this case and proceeded to send a letter to the Medical provider call center claiming that there is no workers comp case in defiance of OWCP's judges and the file and facts, etc. There are documented 'thefts' from Trailblazers which is before you also. The reconsideration decision disappeared from the Miami Hearing office and the judge didn't know one was done. I've had 22+ years of files going missing in multiple agencies. And only a few office managers have filed the required law enforcement reports.
Director of Federal Workers Compensation
In 2007, I talked with the Director of OWCP in Washington D.C. he located some of the file and the 2004 remand orders from the appellate board. He forewarned those to Dallas and a claims examiner was assigned to work through the back log which would have been the paying of the claims in this appeal case. She also 'found' more files that were supposedly sent to the Federal records center in Fort worth. The next thing, i knew, another examiner in the office was directed to say I'd never returned to work in '90 and thus wage loss should not be reinstated and another appeal went back to their appellate judges in Washington, D.C. Without files, 'gossip' came be devastating. The file was obvious that I had tried to work to the point of certain medical death according to the hospital intensive care records. I received a call from a gentleman who said that he worked for ACS and was flown in to shred files of many injured workers. Orders came from the manager who is no longer in the office. Someone had spent a long time blacking out names and numbers. I sent him to US Dept of OIG, and their staff said that their manager refused to stop what was obvious illegal activity. It took until 2/09 for the file to be remanded out and yet there has been defiance of the judges' orders. The new manager, who has no access current system records or paper file ( needs to be reconstructed again) didn't even know there was a 2/09 remand. The President and CEO of ACS took my letter to him and discussed the case with the new manager and 'gossip' got sent out, again. Today, I talked to a gentleman in the Director of OWCP's office and they have the 2/09 remand orders. It could take past the time to appeal this decision before i know if they are going to be able to do anything with ACS in getting claims processed and paid. Medicare Secondary recovery unit had had to work from the national health insurance claims data base to find claims in '05 and '07 that pertain to the Trailblazer cases and other Palmetto GBA cases that are in the pipeline headed to you office or still at the Mimi Medicre hearing office. Their recovery letters were ignored!
General Counsel for Medicare says that what is occurring in a civil rights violations. In 1/08, I filed the first one with the Dallas HHS office of civil rights and was called and 'threatened ' by the manager for filing. Every few months the new incidences are filed and none of the 25 complaints have ever been given a reference number nor assigned to any staff to review and/ or investigate. About a year ago, the reg office manager actually put my complaints and extensive investigations that we've done and mailed them back to me forbidding me to never file another complaint. Washington, DC state that he couldn't do that, but not even the HIPPAA complaints attachment are allowed to be given to the investigator. Most of the parties named as violators are not covered under HIPPAA although the new Director of Medicare is writing regulations to put them under HIPPAA for the future. How does one file a False Claims against an agency? I have legal opinons from two prominent attorneys in the field. Without a through appeals process with rulings on all the issues and discovery that should be done by the Office of Civil right sin those cases the cost is estimated at 2 1/2 million to bring a suit. Few Medicare beneficiaries have enough bills. Even the 17 pays for claim by trailblazers with only one going to the medical provider is only about $4 million.
I was chagrined at the potential loss of lives of beneficiaries if there are no more conditional payments under medicare. I've signed enforcement orders against insurance companies when the intermediary asked me to review the case before sending on over to the US attorney's office. i know just how deadly the 'games' that can be played with patient's lives and now that includes mine. Your staff indicated that no ' side' memo was sent on this case. However, the Director of federal workers comp was aware that Medicare was getting ' unhappy' about paying OWCP's bills. But they didn't realize that this case was involved?
REQUEST FOR TIME
I'm requesting a 6 month extension of time to see if the Director of Federal workers Compensation will be able to carry out their appellate boards orders. We have a @50, 000 page file to reconstruct so the claims in this case can be processed and paid.
REQUEST TO REOPEN AND REVISE
If there is no progress with OWCP's contractor or the regional office to comply then I'm asking you to reopen and revise and process the claims from all three suppliers that go back to 8/1/00 and pay them as conditional payments and ask the Director of Medicare to enforce the repayment by the US Dept of Labor. Reconstruction may need to be made. Lincare and Rhema need to be notified by CMS or intermediary.
OFFICES OF INSPECTOR GENERALS
OIG's are not permitted , by act of Congress , to investigate or refer govt contractors (business associates) for crimes. Also, CMS, has not docketed in one of my numerous complaints according to a deputy sec of HHS that went and checked in 4/09. There are many filed over the years by fax and mail. Also, US Dept of Labor's oig investigation of the Dallas office years ago, resulted in ACS getting the contract and things getting even worse as no one can even get judges' orders to them without ACS deciding if they should post it first. Before I was transferred to OWCP jurisdiction on 10/11/94 for the last time, The Sec of HHS sent out a memo that basically suspended the enforcement of conditional payments under Medicare by placing the insurance liability industry on the 'honor system. I knew from personal experience it wouldn't work. little did I realize that in 2010 I'd be asking your office to reinstate it for injured federal workers and also against Federal employee health benefits. As the general counsel for OPM stated a few years ago before I learned how intentional the alteration of the legal line up was and I thought it was poorly trained agents who didn't know that working and employment are two different legal terms. ( not going to work= retired); there is no inactive employment for a federal employee. She pulled up my records and I verified she had them, including my agreement with SSA, you are an active federal worker until Federal workers comp gets you on their permanent disabilty. DON'T FORGET FEDERAL WORKERS COMP LAW OVERRIDES all other laws on you. I filed for permanent disability ( schedule award) in 1996, many doctors have signed and submitted documentations, etc. only to routinely have the filings 'disappear.' There is a 22+ year back log of various items that have never had an initial decision and they have all been kept currently pending by me and my family at great personal and financial expense.
WAIVER
In file was a request to hold me and my suppliers harmless from any liability. That was not addressed. Judge carter had indicated that I could be held liable. My life is at stake and I have done every thing humanly possible to the point of filing bankruptcy over this. I'd hoped the bankruptcy court would help and not discharge immediately , but they did so even though they had the decisions form Judge Carter as well as The appellate board's decision from US Dept of Labor. We fully informed the court of what was due and payable. Our attorney had us list CMS and the millions of dollars involved. Thus all liability against us from Medicare or medicaid has been discharged. Lincare was paid double for a period of time. But Federal blues took back thousands of dollars in 2002, claiming Medicare should pay first and ignoring any workers comp involvement. It's a convoluted 'legal night mare ' created by the defiance of judges' orders, over and over, and constantly altering official records in violation of companies contracts and agreement with various federal agencies.
Now, my husband's and daughter medical treatment are being sabatogued as they are on my federal Blue Cross/Blue Shield and my status determines who pays first on them and we are having to file appeals on their claims now.
All, I did was go to work one day and do my federal job and a toxic cloud enveloped me and the 'fight to stay alive began from the first day when my own govt ordered hospitals to turn us all way and deny treatment. I was the last one registered in at one of the hospitals, and so badly injured that someone else gave info . My AFGE Union Health insurance card was pulled out and mistakenly I was listed as A Port Authority employee and getting required tests run and treatment started and being prepared for admission until a doctor came to fill out the required toxic exposure report for the New Jersey state health department, When it was discovered that I worked for HHS-Social security, I was sent 'home to die' as ordered by my govt along with my co-workers. Rushed back by ambulance and a fight ensued at another hospital among doctors and the peer review as more tests showed my extensive injuries, given a shot of anabolic steoroid and sent home again because the govt didn't want us treated at all. Third time to the hospital found me in critical condition fighting infection and I was there for 2 weeks while back at the office, OSHA was getting lied to and accidents reports on all of us were being destroyed and the owner of the building was destroying evidence. I'm told that there is a grand jury sealed indictment with my blood and skin samples in them as evidence against the 'named' party. When, my co -workers began to die from their injuries, I caught even more retaliation as 'witness' against those who ' contributed to the deaths of HHS employees. Until '95, our paychecks and w-2's listed Health And Human Services as employer.
In 4/09, I appealed to your office for assistance in enforcing the law as I used to do for other patients years ago. Cigna Govt Services is the only intermedary that has allowed a timely process of the appeals. Wisconsin Physicians doesn't even have a reconsideration contractor and they have refused since '07 to answer redeterminations. Trailblazers, blatantly ignore and defy the constitutional appeals process also. Monies have to be spent putting appeals together and asking the claims to be coded as conditional payments and collections done from the appropriate primary payer. All of my Medicare claims that have been paid are either for accepted conditions at OWCP or secondary and/ or tertiary claims have been filed that have gone unreviewed for years in defiance of the appellate judges who cmentin them and sate they can't review something that has never had a decision.
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CC: Cigna Govt Services
CC: Palmetto GBA
CC: Lincare
CC: Rhema
CC: All About Mobility
CC: OIG CMS
CC: OIG US Dept of Labor
CC: OIG HHS
CC: Alan Porwich ESQ.
CC: Director Of Federal Workers Compensation
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