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Discovering Medicare Fraud and Restoring Access to Crucial Lifespark Services

  • Sep 14, 2023
  • Cathy Gasiorowicz
  • 5-min Read

Since the death of her husband, Marla* had been living on her own with some help from her adult children and her power wheelchair. But between her atrial fibrillation, congestive heart failure, edema, and ongoing difficulty finding reliable in-home care providers, she knew she needed more support. So, in early March 2023, she moved to a Lifespark Senior Living Community in the same town as one of her sons, who is also her power of attorney (POA).

As a UCare Medicare Advantage member, she was introduced to Lifespark COMPLETETM which would give her access to in-home primary care and a dedicated Life Manager. She signed up immediately.

After a four-day hospital stay in late March, Marla, 95, was back in her new assisted living apartment and under the care of Lifespark Gerontology Nurse Practitioner, Emolebi Akpojotor, NP, who had been monitoring her INRs, medications, and overall health. Marla’s COMPLETE team also included her Life Manager, Kristin Soderholm, OT. They had met once and were about to begin the discovery process for creating a Life Plan.

But shortly before their second meeting, there was a change in plans. Literally.

Bait and switch

It started with a phone call from the Lifespark billing office, said Casey Iverson, LPN, nursing coordinator for the assisted living residents. “They explained that Marla’s insurance had changed and that as of May 1, she was no longer eligible for Lifespark COMPLETE,” she said. “I was surprised because I knew how much she liked Kristen and Emo and now she’d have to find an outside primary care provider.”

Even though Emo wasn’t able to check Marla’s INRs herself, she continued to monitor them to watch for any changes. As for Kristen, she wanted to keep her scheduled appointment with her now-former client.

That’s when she learned what had happened. “Marla told me that when she was in the hospital, someone had approached her and promised that if she signed up for this other insurance plan, all of her medical bills would be covered,” Kristen said. “She was in a panic and blamed herself.”

With Marla’s permission, Kristen contacted the insurance companies to verify the changes and then explained to Marla that during the fall Open Enrollment Period, she could re-enroll in UCare but that it wouldn’t kick in until January 1, 2024. “I told her that I’d put it on my calendar for Oct. 15 [the start of Open Enrollment],” she said.

Huge team effort

After their visit, Kristen sent an email to Lauren Fahey, Lifespark COMPLETE Enrollment Specialist, letting her know she had confirmed the changes with both insurance companies. “I give Lauren full credit for digging in and identifying Medicare enrollment fraud,” Kristen said.

The first thing Lauren did was notify the team that she would do everything possible to get Marla back access to Lifespark COMPLETE. Then, she called Marla’s son, who is also her power of attorney (POA), to make sure he knew what was going on (he did) and that they were all on the same page (they were).

Next, she navigated the Medicare system. Between Lauren’s understanding of Marla’s complex medical needs, and her son’s role as POA, the team submitted a detailed claim focusing on two key points: first, that the member was misled by an outside insurance agent, and second, that losing access to crucial medical services would be devastating for the member’s health.

Within a couple of days, the Centers of Medicare and Medicaid Services (CMS) notified Lauren that Marla’s UCare Medicare Advantage plan had been reinstated. At Lauren’s request, UCare seamlessly reinstated Marla’s Medicare Advantage plan and backdated her coverage ensuring uninterrupted access to her COMPLETE team—Emo and Kristin.

Full support restored

When Kristin, OT, Life Manager, learned that Marla’s UCare Medicare Advantage plan had been restored, she was delighted to be the one to share the happy news with her client. “I came into her room and said, ‘Yay! We’re back on! Let’s get you on my schedule,’” Kristin said, adding that Marla was elated, as was her son. “This whole experience is a great example of how everyone at Lifespark jumps right in and uses their skills to help our members get exactly what they need,” she said.

Since then, Kristin and Marla have continued to meet and talk about goals, priorities, and wishes. “One of the things I love about my role as Life Manager is having the time to get to know each member, build rapport, and have discussions around questions, like ‘What’s most important to you? What’s lacking in your life? What can we do to bring you more joy?’” Kristin said. “Aging magnificently is about more than just expert medical care—it’s about the whole human experience.”

To learn more about Lifespark and how we advocate for senior and their families, visit lifespark.com/complete.

*Name has been changed to protect client privacy

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