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An Advocate’s Story (The names of the consumers were changed)

When I first interviewed for the position of Advocate with Westchester Disabled On the Move, I asked the Executive Director what the average day would look like. I heard: “There is no average day here. Every day is different, and every situation unique”.

Indeed I saw for myself very quickly that it was exactly like my boss had said.

One of my first cases was an elderly lady, Jane, whose daughter Georgette came to us for help at the end of March. Her mother was declining in her ability to comprehend and participate in the adult day care services her insurance provided, and it was time for her to start receiving services at home. The daughter requested a change, and here is where things got very interesting. It is also when my colleague, also an advocate, and I came in to assist Georgette with the complexities of the situation.

First of all, the Managed Long Term provider took their time before they sent a formal notice of denial to Georgette. Meanwhile, precious time was flowing and Jane’s mental health was declining rapidly. She was clearly becoming very unhappy outside of her home. It was time to slow down. The provider had other ideas, though.

After an attempt to negotiate informally with the insurance provider and getting nowhere, our team decided it was time for a fair hearing. It was scheduled for mid-May. Extensive preparations are necessary to facilitate such a meeting which happens in front of a judge and is legally binding. You do not want to make a mistake. My fellow advocate and I met with Georgette, prepared stacks of documents from doctors, nurses and aides. Everything was ready to go for the hearing. On the day of the hearing, we all came to the Department of Social Services (DSS) dressed to kill and ready to argue the case.

Can you imagine our frustration when after an hour of waiting we were informed the other party was not going to be present. They did not even bother to inform anyone. It was back to the roster: waiting for the next available date on the judge’s calendar.

Meanwhile, Jane was still stuck.

The next fair hearing was scheduled for the end of June. This time it had to work. After all, the judge had ordered the other party to appear.

The June hearing date arrives. We get more documents ready, travel again to DSS, and sit in front of the judge. The other party is there. We are well prepared and expect a fairly intense discussion. The judge reviews the documents, and the unbelievable happens. The hearing is adjourned again. Apparently, there is some technical issue concerning the documentation and we are not able to proceed. The judge orders a new evaluation to be scheduled. Another delay. It is our second time being turned away and coming back with nothing.

Meanwhile, Jane is still not home.

It is now early August, four long months since we first requested the change of services for Jane. At this point, no one is returning our calls and we are being transferred from person to person in search of answers. The evaluation was done, but nobody knows the result. Some of the workers do not even know what we are talking about. We contact the Grievance Department and demand a resolution to this matter. It has been way too long.

Mid-August; things are finally looking up. After contacting several high ranked officials at the provider, all of a sudden the issue is miraculously resolved to our satisfaction. A few days later, Jane is happily enjoying her own home environment with 24 hour care provided by the same provider.
It was supposed to be a simple matter, but we had to do a lot of gymnastics to make it happen. One more case solved! It is a reason to be happy and celebrate. Until next time.

The consumer told us she will never forget what we did for her. She said she was so frustrated with the process that at some point she considered giving up. Our team continued to call and encourage her not to give up. We made periodic calls to the provider until we got our answer. Our collective expertise helped us locate the key people in the managed care organization and make sure they resolved the issue. Georgette says we saved her peace of mind and her sanity.

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