Woman, 71, fights back against Medicare – and wins!

Anita Chapman did it all by herself. The self-described Wise County girl from Texas took on one of the biggest challenges of her life. She fought Medicare over a $1,400 bill for an ambulance ride from her Haltom City home to the hospital.

Ever since her husband died a few years ago, it has been hard being on her own. “I’m an old gal from Paradise who got married at age 16,” says Chapman, 71. “As my daddy said, I went from doing what my daddy told me to do to doing what my husband told me to do. And I’ve never had to go through anything like this.”

On the night of March 2, 2008, Chapman couldn’t stand. Her doctor later described her symptoms as nausea, vomiting, a headache with severe weakness and spasms. A friend came by to help but couldn’t get her up. The friend called 911.

Paramedics took her out on a stretcher and gave her an IV solution for dehydration. She spent the night in the hospital.

A few days after coming home, she was notified that Medicare wouldn’t pay the $1,400 ambulance bill. She made a few calls and was told the bill was rejected because she didn’t need an ambulance. Unless she could prove otherwise, she had to pay the bill.

“It made me feel that I had to fight back and do something on my own,” she says.

So Chapman stepped into a bureaucratic maze of Medicare appeals, a multilevel system with strange terms such as redetermination specialist, adjudicator and administrative law judge. She worked long hours to complete Forms CMS-20027, CMS-20033 and CMS-20034B. She used a fax machine for the first time. In doing so, she set herself apart from most, Medicare specialists say.

“She’s one of the very few who continues to push Medicare,” says Pam Roach, the Medicare billing supervisor at MedStar Emergency Medical Services, which supplied the ride. “I know it’s hard for her, but a lot of the elderly don’t make the effort. They don’t have what it takes to fight the system like that.”

An advocate agrees with the sentiment. “Good for her, because there’s not a lot of help out there for these appeals,” says Judith Stein of the Center for Medicare Advocacy.

Chapman’s journey has lasted a year. It started with her request for a redetermination, which was denied by the federal Centers for Medicare & Medicaid Services.

The second appeal went to an outside company hired by the government. It denied the claim, explaining, “There was not an immediate threat to the patient’s life, limb or functioning of a body part, and the service does not meet the coverage requirements.”

After that, she received a warning: “IF PAYMENT IS NOT RECEIVED WITHIN 15 DAYS, YOUR ACCOUNT WILL BE REFERRED TO COLLECTION AGENCIES AND CREDIT BUREAUS.”

“Now that scared me,” she says. “Because I thought they were going to come to my door and take me to jail. I’ve never had a collection agency in my life. My husband paid every bill when we got it. We never bought anything on credit. The car, the house, everything we bought, we paid cash for.”

Of course, she appealed. An administrative law judge read a letter from Chapman’s doctor and another letter from Chapman’s friend that she was unable to get Chapman to stand. The judge also read the other side’s argument: The patient could have traveled “by any means other than ambulance service without endangering his or her health.” He never held a hearing.

The judge’s ruling arrived this month. When Chapman opened the letter, she first had to read through four pages of information about how to appeal. For sure, she thought she had lost again. Finally, on Page 5, she saw the words “FULLY FAVORABLE.” She read it again. And again. She won!

“You could have heard me shouting clear over Fort Worth,” she says, laughing. “If I hadn’t sent all that stuff in, I would have had to pay $1,400!”

The judge’s documents-only ruling shows the case never should have gone that far, Medicare advocate Stein says.

“Going from home to hospital in an ambulance should be covered in most circumstances,” she says.

There are two more steps.

Medicare can appeal to the Medicare Appeals Council by May 2. If Chapman loses that, she can ask for a judicial review in U.S. District Court.

So she waits. “Oh my gosh, are they going to make me do it again?”

“Come on,” MedStar’s Roach says. “Somebody have a heart.”

The Medicare site about appeals is www.cms.hhs.gov/orgmedffsappeals. An advocate’s site is www.medicareadvocacy.org.