HJBR Jan/Feb 2026

HEALTHCARE JOURNAL OF BATON ROUGE I  JAN / FEB 2026 11 regardless of whether a patient requires more care.” 2 Another class-action suit filed around the same time against UnitedHealth and its codefendants accuses that insurance giant of doing the same thing, with the same tac- tics, and with the secretive aid of the same unregulated, proprietary algorithm used by Humana. 3 While those class-action lawsuits were filed around the end of 2023, we didn’t learn about them and how Humana’s AI model controls the whole process until months later. Following Humana’s denial of our appeal, Yvette tried a different tactic. On Thursday, Sept. 28, she wrote a letter on our behalf to the third-party arbiter, Maximus. According to the Centers for Medicare &Medicaid Ser- vices (CMS), Maximus is what’s known as a Quality Improvement Organization (QIO). QIOs are independent agencies under the umbrella of CMS that, among other things, look into Medicare patients’ complaints about insurer denials of care. 4 Maximus — a $5.3 billion corporate entity — represented our next level of appeal. Yvette told Maximus how Mom’s physi- cian, “as well as her physical, occupational, and speech therapists, are recommending continued twenty-four-hour care upon dis- charge,”and that, “at this time, Skilled Nurs- ing Facility care is medically necessary as the patient continues to require daily nurs- ing care, as well as daily therapy from skilled therapists.” The next day, Maximus mailed Mom a letter introducing themselves and explain- ing what came next. “Medicare hired us to review the appeal,” they said. On Saturday, Sept. 30, Maximus sent a notice saying they agreed with Humana. “If you do not agree with us,” Maximus con- cluded, “you may have rights to review by the Office of Medicare Hearings & Appeals (OMHA). This review can include anAdmin- istrative Law Judge (ALJ) or an on-the- record review by an Attorney Adjudicator.” The IRF discharged Mom on Tuesday, Oct. 3, eleven days after Humana cut off coverage. In addition to continuing to care for her around the clock, the IRF had kept up Mom’s rigorous therapy schedule for a week and a half, and, as far as I know, on their dime. Mom transferred to a SNF that afternoon, but not the one we originally chose. Since we had no clue how long Mom would be paying more than $6,000 out-of-pocket each month for what’s officially known as “respite care” while we fought Humana at the next level of appeal, we chose a less expensive SNF. The second week of October saw Mom begin to receive physical, occupational, and speech therapy three times a week, as opposed to five times a week, like she would have gotten under skilled nursing coverage. These sessions in the SNF’s therapy gym were approved by Humana under Mom’s Part B outpatient therapy benefits. Since Momwas already in the SNF (on her dime), these “outpatient”benefits were received on an inpatient basis. The fact that Mom was there for “respite care,” because Humana denied her skilled nursing coverage, was inescapable. We were repeatedly told that Mom couldn’t get certain equipment because she was not a skilled nursing patient. For instance, during her monthslong stay at the SNF, not once did Mom get to use a requested recliner to have something to sit on besides the bed or wheelchair, even when a recliner lay idle just outside her room for days. On Oct. 16, Edie filed our request for an administrative law judge hearing, our next level of appeal. Her brother Patrick is a law- yer who represents people claiming disabil- ity in hearings before administrative law judges, so we turned to him for advice on how best to approach our hearing, when- ever that might be. He said we made a smart move by not bringing Mom home while we appealed. Paying for respite care proved our point that we were incapable of caring for her at this point, Patrick explained. After reviewing all of the documenta- tion, he came up with some interesting find- ings, like how both Humana and Maximus inaccurately cited Medicare guidelines to justify their denials. In listing the four fac- tors for SNF coverage, they consistently omitted a vital qualifier prefacing the third one. “As a practical matter, considering econ- omy and efficiency,” the omitted opening phrase declares, before the rest of the cri- terion states, “daily skilled services can be provided only on an inpatient basis in a SNF.” 5 Yvette called attention to this omis- sion by Humana in her letter to Maximus, and even cited guidelines for determining what constitutes a “practical matter.”As I’d later explain to a federal judge, “This omis- sion abdicates Humana and Maximus from any obligation to consider the impracticality, the undue economic burden, and the gross inefficiency of forcing my mom to receive daily skilled services on an outpatient basis, and thereby affords them a made-up excuse to deny SNF coverage.” In my two decades of officiating football at the high school and college level, I spent much of that time teaching the game’s com- plicated rules to other officials. Along the way, I learned something important that transcends sport: The mushier the rules, the more rigged the game. Thanks to a comedy of bureaucratic errors, culminating in the arrival of an encrypted CD and an incorrect password on the eve of our Dec. 7 telephonic hear- ing, we effectively flew in blind. Thankfully, the administrative law judge assigned to our case, Robert Clarke, made our case for us before we ever got a chance. From Mom’s room at the SNF, we heard him press Humana’s medical appeals spe- cialist, Laura Vanden Heuvel, to explain Humana’s original basis of denial, the one that claimed Mom needed custodial care. She responded by handing things over to Esther Hargrave, MD, Humana’s medical director for grievances and appeals, who also attempted to dodge the question. Con- fronted by the query, Hargrave struggled to answer under oath; Mom felt sorry for her. 6 Partly because we had no access to any of the files pertinent to Mom’s case, Judge