Drug delivery system could use a checkup

Garden Grove resident In Sook Yeo was stunned last August when her Medicare prescription drug benefits were denied by her local pharmacist. Soon after, she received a letter from the state regarding her death.

Her husband, Woon Seung Yeo, had recently passed away after suffering heart problems for years. But through a bureaucratic mix-up, Medicare listed In Sook Yeo as the deceased.

“How can this be?” recalled Yeo, 76. “You have no idea how many tears I shed. It was too much for me to bear.”

Four months later, her Medicare and Medi-Cal benefits -- government-assisted health programs for elderly and low-income people -- were restored. But even then it took three more weeks to reestablish her prescription drug coverage, and only after The Times inquired about her case.

Yeo was caught between two agencies. Medicare assigned her to a prescription drug plan managed by Health Net Orange, which had no record of her. Yeo spent weeks going back and forth between Medicare and the provider trying to resolve the problem.

Before her plan was finally reinstated, she was forced to rely on free drug samples for her indigestion and had to go without a drug to treat her liver, which is affected by dormant hepatitis B.

“You don’t have a place to go when you don’t have Medicare,” Yeo said. “I wished that would be resolved in a hurry.”

Yeo is not the only Medicare recipient to have lost her prescription benefits for weeks at a time because of a bureaucratic breakdown, according to healthcare advocates.

Beneficiary counselors in Los Angeles, Orange and Ventura counties have all reported problems or delays after filing complaints with the agency’s regional office.

“It’s been difficult to get a complaint filed, let alone get a response,” said Cheryl Meronk, program manager of Orange County’s Health Insurance Counseling and Advocacy Program. “It has taken at least two weeks to get an initial response back from anyone.”

Medicare officials defended the agency’s approach, saying it’s in the best interest of each drug plan provider to resolve complaints lodged against them.

“The plans really have to be involved,” said David Lewis, a Medicare official. “They are the ones delivering the service.”

But David Lipschutz, staff attorney for California Health Advocates, a nonprofit organization that works with groups that counsel Medicare beneficiaries, said the federal agency is chiefly responsible for managing the drug program and that its approach to corrective action is flawed because of a lack of government oversight and enforcement.

Under the current system, beneficiaries can call 1-800-MEDICARE to register complaints, but the complaints are then forwarded to their private drug plan. So the onus is on the provider to resolve the problem in a timely manner and to inform Medicare of the outcome.

The result can be lengthy delays in correcting problems, Lipschutz said.

Medicare “has turned over too much of its oversight to the private plans themselves and is relying on an awful lot of self-policing,” he said.

“Oftentimes, the beneficiary gets bounced around from place to place in a round robin of finger pointing without resolving problems at all.”

Even after a person files a complaint to 1-800-MEDICARE, callers are told not to call the number again because their complaint will be forwarded to their provider, according to a Medicare tip sheet.

If problems persist, the tip sheet advises beneficiaries to e-mail their complaints to Medicare’s regional office, which is in San Francisco for not only California but Arizona, Nevada, Hawaii, Guam, American Samoa and the Northern Mariana Islands.

It makes no mention of how to reach Medicare staff on the phone.

Medicare’s policy is for the drug provider to resolve emergency cases within two days, and all other cases within 44 days.

The federal agency also has caseworkers available at regional offices to deal with complaints, he said.

“We monitor and make sure each of these complaints is resolved,” he said.

Still, delays persist. Medicare spokesman Jeff Nelligan apologized for the trouble Yeo endured, but said the agency “resolved the problem as quickly as possible” once the Social Security Administration contacted them about the mix-up. A Health Net spokesman said Medicare had incorrectly assigned Yeo to its drug plan instead of her original provider.

“It’s a clash of systems and we’re sorry it took about a month,” Nelligan said.

In another instance, Seal Beach retiree Vivian Hinsley, 74, believed that she was overcharged for a prescription drug intended to prevent her from getting cirrhosis of the liver. Her cost had risen to $766.39 for a 90-day supply, but Costco charges about one-third the price.

A counselor assisting Hinsley called Medicare and her drug plan, Secure Horizons, in mid-December to register a complaint. But for weeks neither Medicare nor Secure Horizons called her back.

“I think that they should at least call me,” said Hinsley, who is paying off her prescription drug bill with a credit card. “It’s a heartache. I sure don’t like it.”

Within hours after The Times inquired about her case, Hinsley said she got a call back from a Secure Horizons official who told her to file her complaint in writing. A Secure Horizons spokeswoman said the company did not have any record of her complaint.

Anaheim resident Barbara Risco, 67, spent the first business day of the new year on the phone with both her drug plan, Health Net Orange, and Medicare after her pharmacy rejected her prescription. She had already received a letter from the drug plan informing her that she could get drugs at the beginning of the year.

When contacted about the discrepancy, Health Net Orange told her to call 1-800-MEDICARE to resolve the issue.

“Medicare was a nightmare,” said Risco, who ran out of her cholesterol-lowering medication. “They didn’t know what to do. They disconnected me. They transferred me all over the place. They said you have to deal with Health Net,” which led her back to where she started.

Risco got her prescription filled a day after The Times inquired about her case.

Health Net spokesman Brad Kieffer apologized, saying the plan should have resolved the problem after Risco first called.

“I’ve never been in a bind like that before, where Health Net wouldn’t help me and Medicare wouldn’t help me,” Risco said. “If someone runs into a problem, someone should help them.”

ron.lin@latimes.com

connie.kang@latimes.com