Client Services Counsels Take on Complex Medicare Cases

The staff and volunteer counselors on the Medicare Rights Center’s National Consumer Helpline answer Medicare questions from consumers, caregivers, and professionals every day. Yet there are times when a counselor will come across a complex situation where a client needs more assistance than a helpline call can provide. That’s when Medicare Rights’ lawyers step in with their expert knowledge of Medicare rules and regulations.

Beth Shyken-Rothbart, senior counsel for client services and New York policy, and Jake McDonald, client services counsel, take on casework and supervise client services staff in their roles. Casework can involve communicating with insurance companies, health care providers, and government agencies. While the counsels advocate on behalf of their clients, they also empower clients to advocate for themselves.

“If a person seems capable to advocate on their own, we’re going to encourage them and give them the best guidance possible,” Shyken-Rothbart said.

Both Shyken-Rothbart and McDonald are lawyers, which is crucial to interpreting and researching Medicare regulations. “Medicare covers nearly 60 million people, so the rules just don’t imagine everyone’s situation,” McDonald said. Medicare rules are constantly changing, and keeping up with those changes is vital to understanding how they will affect people with Medicare.

“Having staff with extensive knowledge of Medicare’s rules is imperative to navigating intricate Medicare issues with our clients,” said Fred Riccardi, vice president of client services.

While some cases are resolved through bridging communication gaps, others require more research and follow up. In appeals cases, for example, a client challenges an Original Medicare, Medicare private plan, or drug plan’s decision not to cover a health care service or item. Higher-level appeals include a hearing with an administrative law judge (ALJ). Shyken-Rothbart and McDonald, when necessary, represent clients during ALJ hearings, at which time the person appealing usually provides testimony and evidence by phone.

Medicare Rights also trains law students to become Medicare experts through its Legal Intern program. This year, Zoila Sanchez and Dejana Mladenovic each had the opportunity to staff shifts on the helpline, assist with casework, and conduct research projects. Mladenovic, for example, researched Medicare changes resulting from the opioid crisis to help counselors conduct more informed, empathetic helpline counseling.

Medicare Rights’ casework both helps individuals and informs its larger mission—clients’ experiences influence policy work to advocate for access to affordable health care for older adults and people with disabilities.