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The Bill and Marie O'Dell Story
This is a case where it appears that Kaiser has a separate diagnosis for a patient but is not willing to admit to in writing because that would be an admission of Medicare Fraud and Breach of Contract with the O'Dell's. According to Mr. O'Dell, around 2 years ago Marie's Kaiser physician said that he thought she had SIADH ((syndrome of inappropriate anti-diuretic hormone). Bill O'Dell found on the internet that this could be caused by cancer of the lung and a requested that Kaiser do a workup to find the true root cause of her SIADBill requested and demanded that she be tested
for this disease.
Kaiser refused to examine her and gave them the explanation that she was too old and ill for them to provide any treatment. Kaiser has currently placed Marie O'Dell in their Home Hospice Program, with the diagnosis of "Failure to Thrive." She has been prescribed Morphine to take in liquid drops under the tongue for breathing problems. Kaiser previously had placed her on their straight Home Health Program, for about one month, on paper. Little service was provided for her under this program.
local funeral director has also advised Mr. O'Dell that if he
did not place her in the Kaiser Hospice Program, that upon Marie's
he might be under suspicion of murder. The funeral director
to Mr. O'Dell that under Oregon State Law that if Marie is under the
of Kaiser Hospice at the time of her death that he will not have any
from the law enforcement authorities. - May 12, 2003
The following is a compilation of letters from Mr. O'Dell to myself:
My wife was admitted to the hospital November 2001 with extremely low sodium (that causes dementia-like symptoms). Well despite two CHDR (Center for Health Dispute Resolutions) in our favor stating that Kaiser had to give my wife Skilled Nursing Care until she got well or her Medicare benefits ran out Kaiser has refused to give her one day of SNC. She was readmitted to the hospital one month later with identical symptoms and Kaiseragain refused SNC saying that it was a different case and that I would have to appeal to CHDR all over again.
I have been appealing through Social Security and CHDR and Administrative Law Judges for the past two years but still my wife suffers and gets minimal help from Kaiser. Even though we paid $600/mo for ten years ($72,000) for just her Medicare Plus II policy that was supposed to cover Nursing Care. . Kaiser has decided because my wife broke her right leg then fractured her right hip (they may have put too long a rod in her leg) that these two operations cost them almost $50,000 so my wife was an expensive patient. Now they define that she has dementia and say to read the fine print dementia is not covered in your Medicare Plus II (now called Sr. Advantage II) policy.
The first appeal to the Administrative Law Judge was thrown out by him , without even allowing me to appear, because he said the CHDR had ruled in our favor. I appealed this decision to the Social Security Administrative Review Board saying that is why I was appealing the case because CHDR had ruled in our favor but that Kaiser refused to follow the CHDR decision.
I have tried to contact attorneys in Oregon and they all say find a doctor to disagree with Kaiser and then come back to us. Well, if I knew what doctors would find fault with Kaiser I would go to them but I don't. Also because my wife has diabetes we cannot just quit and go to some other medical HMO or Blue Shield, in other words we are stuck.
Have you any knowledge of doctors or lawyers in Oregon that can help us Oregon residents stuck with Kaiser? Kaiser gave my wife about seven IV's of sodium in a three month period each time declaring her "medically stable" and could go home or to Custodial Care (not covered by Kaiser). She had to be re-admitted to the ER within 48 hours after being discharged from Kaiser hospital then within 12 hours after being released from the ER as "medically stable" she had another seizure and her eyeball popped out of its socket. Some medically stable, huh? I have tried to contact the media (TV, newspapers) but because Kaiser advertises the media does not want to lose Kaiser's advertising dollars.
I had the Administrative Law Judge Hearing Thursday with the same Judge that dismissed an earlier appeal because CHDR (Center for Health Dispute Resolution) had ruled in our favor. In this hearing he would not allow any mention of the case that he already dismissed and stated that because Kaiser paid $400 of respite care that was equivalent to over $22,000 that 100 days of Skilled Nursing Care would have cost them. Although it will take 90 days to six months to get his decision he pretty well signaled that he was going to rule against us. The only thing positive was when he heard that Kaiser took four days instead of 24 hours for the Protime Clinic to call me and tell me to quick stop the coumadin blood thinner your wife is way too high, followed the next day by my wife's mini stroke (TIA attack) and the fact that my wife had her eyeball pop out of its socket due to having a seizure 12 hours after being released from the Kaiser ER as being medically stable the judge did say that I have a medical malpractice case against Kaiser but it does not belong in his court.
I am attaching a one page fax that I have sent to Oregon US Senator Gordon Smith concerning this prejudicial hearing saying that they should do away with ALJ, CHDR, and CMS to save taxpayers hundreds of millions of dollars if Kaiser can come out and rule again that a patient does not qualify for Skilled Nursing Care after CHDR ruled that they do.
December 14, 2002
Senator Gordon H. Smith
Dear Senator Smith,
Re: Office of Hearings & Appeals, CHDR & CMS ref. Grace Marie O’Dell,
On Thursday, December 12, 2002, I attended the Social Security Hearings & Appeals hearing of Judge Joseph Schloss on two of our five ALJ appeals that I filed this year and found it to be an unfair, biased and prejudicial hearing more than you could imagine. Judge Schloss who had ruled in July of this year dismissing a previous case without even affording us a hearing on that date because CHDR had ruled in our favor started the first twenty minutes by not allowing into evidence most of the exhibits that I had submitted. He refused to subpoena additional Kaiser medical records that would refute Kaiser’s claim that Kaiser had solved my wife’s immediate medical problems and the evidence of the 97 errors in the Kaiser medical records that were in the case files. He led the expert witness to state the Judge’s pre-conceived notions. When I asked the doctor if additional medical evidence might change his mind the doctor agreed with me. Judge Schloss then restated the question by asking the doctor if what was in the present records would justify Kaiser’s position that my wife only needed Custodial Care from December 17, 2001. To which the doctor agreed with the Kaiser decision. He avoided placing into the case files that within 72 hours of her release from the hospital she had to be re-admitted to the hospital ER for the same low sodium issue. Then within ten hours after being again released as medically stable from the Kaiser ER room she had still another seizure due to low sodium and her eyeball popped out of its socket which is a condition requiring much greater level of care than “Custodial.” The Judge biased and prejudiced my case.
By Judge Schloss not allowing the 97 medical errors to be introduced or individual Kaiser Lab test results that supported my claim and refuted Kaiser’s claim that discontinuing hydrochlorothiazide solved her low sodium problem Judge Schloss showed his bias and did not afford me a fair hearing.
Judge Schloss stating that Kaiser met the Medical Center for Health Dispute Resolution by providing $400 of respite care instead of the approximately $22,000 that the “skilled nursing care” would have cost also shows bias and denied my wife the urgent and immediate medial care that she required. Kaiser paying some incidental expenses or by “re-evaluating” and applying the same Medicare criteria that CHDR had refuted not once but on two occasions shows Judge Schloss’s bias. This defeats the purpose and charter of the Center for Health Dispute Resolution. If the HMO can again go out to the home and refute the CHDR decision. If this is the case Congress should just do away with the whole CHDR, CMS & ALJ organizations and save the taxpayers hundreds of millions of dollars. This organization was set up to resolve disputes between Medicare patients and their HMO’s. If the HMO and/or the Administrative Law Judge can allow their decisions to be easily overturned it defeats the whole system.
Judge Schloss ended by criticizing me for trying to contact his office people when I was requesting by the Freedom of Information Act the two pages of exhibits to see that the records that I previously submitted were in fact entered into the case files. I told him that since he informed me that whatever I sent to him I also faxed to Kaiser. I was calling and faxing his office people to get the undated exhibit lists. I can send you, upon request, all copies of correspondence that I sent to his office. It all centered around the updated exhibit list the date of the trial and other public information that I should have been provided when I first requested that Judge Schloss send to me.
Please look into this matter for us, why the most recent Pre-Service claim of MRI with dye and sedation with CHDR is taking over two months instead of the 30-45 days, and why CMS is not answering your previous correspondence on this matter. My wife continues to have low sodium a year after being released from the hospital and Kaiser refuses to get to the true root cause of her illness. Thank You.
O’Dell, husband, medical representative and POA for Grace
O’Dell, Medical Case Number Removed.
I have not gotten a second opinion yet as all my time was taken either with Marie or preparing for the stupid hearing. I did check with Quotesmith.com and they had an attractive Medigap policy but when I got closer it was only for CA and they could not write in Oregon. Our local Sisters of Providence hospital has an HMO type but I am afraid of that type plan now and want only Medicare plus Medigap.
This week I plan to check into a second opinion from a doctor that the Alzheimer's Research group recommended (that is close to our home) or OHSU (Oregon Health Science University) but that is further with crowded parking. Like I said with Marie I can only go about one hour from our home plus with her dementia-like symptoms I have a 36 hour day. I am only getting 3-4 hours of sleep a night. The reason that I don't believe Kaiser that she has true dementia is that it came on so quickly and twice in the past year as her sodium level approached 140 (normal range is 136-148) she acted much more coherent. Even the Kaiser Regional Medical Director made the comment, "Oh, your wife doesn't have dementia as she answers my questions, knows that she is at a Kaiser Clinic and the season." But when her sodium goes to 128 she doesn't even recognize her husband of 39 yrs.
I have also sent an email to Liberty Medical to check what copayments they would charge for Marie's drugs and diabetic supplies as if they accept just the Medicare payments they would greatly widen my chances to get a Medigap policy and to have Medicare plus Medigap and do away with Kaiser plus allow me to go to a different doctor if I am not getting help. Her 10 prescriptions with 500 syringes and 500 blood glucose strips per month would cost us $700/mo. in drug costs and that is what makes the Providence plan not viable.
want to thank you for all your help. You moved me to request
Marie's present condition we can only be gone about one and one
last time I checked with an insurance broker in Portland the
Again thanks for your help and have a happy holiday.
November 4, 2002
Subject: Poor Quality of Medical Care through Kaiser Permanente that OMPRO refuses to investigate, poor quality of medical review on case that they did review and exorbitant increases in Kaiser’s Senior Advantage II charges in 2003.
As medical representative, husband and Power of Attorney for Grace Marie O’Dell, HICN #removed for privacy and removed for privacyB, Kaiser #removed for privacy, I would like file the following three complaints against Kaiser Permanente and the Medicare Quality of Care investigative resource for Oregon namely: OMPRO (Oregon Medical Peer Review Organization).
I faxed OMPRO the attached fax requesting them to investigate Kaiser’s Poor Quality of Medical Care and they refused to investigate on behalf of Medicare, instead telling me to contact my US Senators.
Further concerning the two medical reviews that they did conduct in the past they themselves have a very poor Quality of Medical review missing 97 errors in just about fifty pages of medical records that I found recently in the Social Security Administrative Law Judge records that they sent him. Also, I attach three pages of errors that I sent to OMPRO regarding poor reviews that they have done. Therefore, I respectfully request that you appoint a different organization to conduct medical reviews on behalf of Medicare.
Kaiser has refused to obey two CHDR decisions requiring my wife’s medical care since her hospitalization for extremely low sodium 11/12/01. To this date her blood pressure is elevated (despite taking two drugs) and her sodium and chloride levels are therapeutically low with the 11/1/02 blood test showing Na 132 vs. 136 and Cl as 92 vs. 97. These two can cause dementia-like symptoms which is why for the past year Kaiser has refused to give my wife the needed medical care that CHDR has ruled that they must provide her.
I would also like to protest and appeal the exorbitant rate increases that Kaiser Permanente is imposing on Senior Advantage II patients in 2003. While Social Security increases are slightly over 1% Kaiser’s basic rates are increasing 8.9% plus office visits are increasing by 50% (from $10 to $15), Hospitalizations are going from $0 to $200 per hospitalization, brand named drugs (and Kaiser considers insulin syringes, insulin and most drugs as “brand name”) are increasing by 25% from $40 to $50 for a three-month supply, Medicare-covered medications and Durable medical equipment are increasing by 20% (such as diabetic supplies), urgent care is increasing by 50% from $10 to $15, ambulance services are increasing by 50% from $25 to $50, outpatient surgery is increasing by 400% from $10 to $50, vision allowance is reduced by 19.4% (from $186 to $150), hearing aids have a decreased benefit and yearly limits on Co-pays are increasing by 66.7%. In other words the very crucial medical care that a person needs at the end of life they are increasing the most. Also the total cost increases are way beyond what can be reasonably justified based on raising costs. Therefore, I respectfully ask that you review and reduce the cost increases that Kaiser Permanente are asking for in the year 2003.
O’Dell, husband, Medical Representative and POA for Grace
September 17, 2002
Subject: Request for immediate Medical Peer (PRO) Review of Poor Quality of Medical Care received from Kaiser Permanente.
Dear Ms. Greta Nightingale,
I, as legal health caregiver and appointed medical representative per signed declaration of Grace Marie O’Dell, do hereby appeal and request immediate medical peer review of the Poor Quality of Medical Care received from Kaiser Permanente.
The Kaiser decisions concerning Grace Marie O’Dell, (Medicare #removed for privacyB, started with her admission into Kaiser St. Vincent Hospital on 11/12/01. She was admitted with extremely low sodium (108mg.). Ever since that date, she has had extreme loss of mental functions, not being able to comprehend, sign her name and sometimes even recognize her husband of 39 years.
1 Two CAT scans one at St. Vincent Hospital in November 2001 and one at Kaiser Sunnyside Hospital done in December 2001 both said that the patient moved and the images were blurry. Yet Kaiser was using these blurry images to diagnose her condition as dementia or dementia/Alzheimer’s. After checking with several medical professionals, outside of the Kaiser organization, and discovering that a proper advanced MRI with sedation and with dye for contrast might provide more definitive results I requested on July 25, 2002 this diagnostic testing from the Kaiser Westside Regional Medical Director, Dr. Manny Karlin. After getting turned down I appealed the issue of advanced MRI with dye and sedation, even stating the specific Medicare coding for this test is: #70552 MRI brain w/dye. After receiving two letters from Kaiser denying the testing I received a call from her Primary Care physician saying they were not denying only discussing and he promised to do the testing at Kaiser Sunnyside Hospital. This took from July 25th until August 19th to arrange. After waiting for over three weeks for the testing I discovered when I got the test report gross medical inaccuracies (such as saying that she had marked decline in mental ability starting in October 1991, instead of saying since November 12, 2001 (ten years later). It stated patient movement in all sequences. In other words, either they gave her the wrong sedation or did not tape her head securely. Finally, they did it without the dye that I had appealed and later withdrawn my appeal based on getting the MRI testing with the contrast media as recommended by numerous medical professionals outside of Kaiser.
I appealed this testing, on September 9, 2002, requesting a 72
hour expedited appeal Kaiser denied my request for a 72 hour appeal
that their Primary Care Director did not consider this a medical
I disagree with this denial and with other aspects of Kaiser care that
I consider grossly Poor Quality of Medical Care. We have been
for the correct MRI with dye and sedation since July 25, 2002, and for
proper and correct medical diagnosis of my wife’s medical
November 12, 2001. Dementia and Alzheimer’s did not
come on the 12th
of November 2001, but comes on over several months and years.
may be why Kaiser was reporting the mental decline ten years before it
Another example of Poor Quality of Medical Care is that I spent over two hours on phone hold trying to reach a Kaiser Advice Nurse on Monday, September 16, 2002, and it took over 24 hours before an Advice Nurse returned my numerous phone calls. This concerned my wife’s blood pressure that had been running 190/92 with a pulse of 68 that had fallen to 87/54 with a pulse of 58. I consider such neglect to be extremely Poor Quality of Medical Care and not at all in following proper medical protocol.
Another major complaint of Poor Quality of Medical Care concerns the August 19, 2002, MRI. Although it reported patient motion in all sequences it did report a mastoid inflection in both ears. Despite my attempts to get her into the doctor almost a month has gone by and she still has not been observed by any ENT or Primary Care doctor. This is an example of Poor Quality of Medical Care of an elderly patient.
Another complaint is that Kaiser billed us a copay charge for a diagnostic test and according to their Evidence of Coverage for Senior Advantage II (Medicare plus II) there is no copayment for diagnostic testing or x-rays. I complained and appealed the charge but am told to wait until thirty days for an answer and that is past the payment due date. This is also evidence of Poor Quality of Medical Care.
have been arguing with Kaiser since the November 2001 hospitalization
timeline concerning the 24-hour wait for medical advice concerning
blood pressure dropping in half:
OMPRO complaint regarding Poor Quality of Medical Care 9 17 02\weo
To: Ann Anderson\RN OMPRO From: Bill O’Dell
Fax: 503-279-0190 Pages: 2
Phone: 503-279-0100 Date: October 31, 2002
Re: Your QIO letter of 10/30/02 CC: [Click here and type name]
Re.: Your letter dated 10/30/02 reviewing my formal Quality of Complaint filed January 9, 2001.
You report that on December 24, 2001, my wife’s sodium was low at 128, despite the discontinuation of hydrochlorothiazide 10 days, earlier, Dr. Gordon noted that your wife had continued to get hydrochlorothiazide at home, despite it being discontinued in the previous hospitalization. On December 27, 2001, Dr. Gordon told me for the very first time that the hydrochlorothiazide was supposed to be discontinued. A medicine that my wife had taken for years and was listed on her current prescriptions on her medical records during the 12/15/01 to 12/21/01 stay at Kaiser Sunnyside Hospital. Dr. Gordon said that the Nursing home during the 11/21/01 to 12/5/01 stay was supposed to tell me to discontinue this medicine, yet it was listed as a prescription on her hospital records of 12/15 to 12/21/01. Further, her sodium did not stabilize to normal range, except momentarily by January 6, 2002. Her sodium was therapeutically low when she was released as being medically stable from St. Vincent Hospital, from Kaiser Sunnyside Hospital and until July 2002 when for the first time we got two readings at or above the 136 normal reading. Kaiser had given my wife eight sodium IV’s (to patch her up) in the two-month period then would send her home as “medically stable.” Even after the discontinuation of hydrochlorothiazide her sodium would drop. Tomorrow I will take her for the first blood test of her sodium since the July 2002 normal readings to see if it has dropped again. Note: These tests showed that after one year and with the hydrochlorothiazide discontinued for a year that the Na and Cl are still therapeutically low (132 vs. 136 and 92 vs. 97).
You state that I believed my wife was denied skilled nursing care but the OMPRO’s physician reviewer did not identify any medical record documentation to indicate that my wife had been denied skilled nursing care shows another major inaccuracy. The Center for Health Dispute Resolution determination 2001-19864 12/6/01and determination 2002-00045 dated 3/1/02 both stated that Kaiser Permanente was responsible for my wife’s skilled nursing care until she got medically stable or until her benefits ran out. My wife to this date has not recovered from the series of low sodium attacks beginning 11/12/01, nor has she received even one day of skilled nursing care since her 11/12/01 hospitalization.
Further evidence of both Kaiser’s lack of Quality Care and OMPRO’s lack of Quality to the attention of details is that I recently documented and sent to CHDR, the Administrative Law Judge and to Kaiser ninety-seven errors in my wife’s medical records that both Kaiser and the OMPRO physician overlooked. This proves that the OMPRO physician did not do a thorough and careful job of peer review and I am therefore requesting that CMS find a different organization to conduct Peer Medical Reviews.
When OMPRO dismissed and refused to even consider my documented formal complaint of Poor Quality of Care by Kaiser, September 17, 2002, that documented the two day wait and six phone calls over a two-hour period to get medical advise in an emergency situation among other documented complaints of poor Quality of Medical Care it shows totally unresponsive service.
OMPRO’s PEER MEDICAL REVIEWS have been laced with errors and inaccuracies and I am forwarding to CMS that in my opinion you have not provided me with proper and adequate peer medical review.
Bill O’Dell, husband POA & Medical Representative to Grace M. O’Dell
Cc: CMS Seattle OMPRO fax 10/31/02
Clarifications of errors in OMPRO Letter of 1/19/02
January 25, 2002
Subject: Premature and early discharge of Kaiser patient, Grace Marie O’Dell, Kaiser personal identifiers removed.
I, as legal health caregiver per signed declaration of Grace Marie O’Dell, clarify the errors in OMPRO’s letter of 1/19/02.
1. The first major error was
that the January 10, 2001 and the March
2, 2001 discharges to two different Skilled Nursing Facilities were
The no food for six hours and no blood sugar monitoring for four hours
occurred during the March 2, 2001 discharge from St. Vincent Hospital
Friendship Care Facility. I went with her and she was
at 4 PM, arrived at Friendship at 5:30 PM and received dinner after 6
to OMPRO letter of 1 19 02\weo
of letter of complaint sent to Kaiser member relations concerning
the King City Rehab Facility
Date: February 24, 2001
Subject: Complaint and
statement of deficiencies with the
During the two weeks (January 10 to January 24, 2001) that Kaiser patient: Grace Marie O’Dell, #removed, was a patient.
Please do not use this facility for any future convalescent needs of Kaiser patients and please locate another such facility in the Beaverton area so that your member’s family do not have to drive clear over to Mt. Tabor, or Vancouver, Washington to your other approved locations.
Husband of Grace Marie O’Dell
Today is May 12, 2003
I received word from Mr O'Dell that Marie, his wife has been placed in the Kaiser Hospice Program for "Failure to Thrive" which is a very vague diagnosis. He has been advised to give her morphine, if needed, 0.25 to 1ml under the tongue, for pain and/or trouble breathing.. .