A Family member is currently in a Skilled Nursing Facility (SNF) in NYC. On several occasions the nursing facility has told the family that their Medicare coverage is coming to an end and “Services” will end. Each time they had a meeting with the family this was presented as a discharge notice. However, nothing was received in writing. Of course, the first time the family panicked. Between Google, Medicare and AARP, they were advised to file an appeal. Upon contacting Livanta, the family was told the case was dropped by the nursing facility and that Livanta could do nothing for them. Approximately a couple of weeks later this repeated, again without a written discharge notice. This time, the Family filed an appeal with Livanta. The appeal was denied even after Livanta stated to the family that they had not received a copy of a discharge notice. Again, the family still believed that these were all verbal discharge notices. The last meeting was on Monday July 1st. Again, they were not given anything in writing. On July 2nd, the family was given a written one-page document stating that it was a termination of services, attached was a form to file another appeal this time with C2CInnovative solutions. There was no explanation of what services would be ending and the family did not ask, still believing this was a discharge notice. C2C rejected the appeal. The family has not received the hard copy as of this date. On July 4th the SNF would no longer give the patient physical therapy sessions. Medicare coverage runs out on July 20th.
It was after contacting the office of the NYC Ombudsman, on July 3rd , that they realized that what they had a notice of termination of services and not a discharge notice. Supposedly, this is a common practice of this SNF. if they had been issued a discharge notice they could have filed an appeal with the NYC Health Dept, which would halt any further action by the SNF, until a decision was reached. Since that is not the case, they can’t do anything?
Your Medicare insurance provider has at long last clarified that your family member will no longer receive PT. What reason has been given?
Are you attending these meetings yourself? If you'll forgive my asking, is there any kind of language barrier in the way, here?
You want your family member to remain in this SNF.
You want your family member to continue to receive PT services. If this PT is medically necessary, can you get your family member's lead physician to assist with the reinstatement of services?
This is not my area, but I agree with you that if Medicare coverage for the PT expires on July 20th the SNF appears to have no justification for withholding therapy on July 4th. Did you take this up immediately with whichever manager was in charge on the day?
However, if there is improvement from day to day and the individual is still not able to do the ADLs but appears to be progressing towards that goal then the continuing of PT/OT makes sense and is approved.
It has a lot to do with the quality of therapy in the facility. My dad had one facility that was like, oh boy he can transfer from bed to wheelchair and back again, baseline, time to go home. I had him transferred to a facility that has fabulous therapists and they kept him for 45 days, all covered by insurance and he walked out the doors doing all of his ADLs. They worked his butt off and encouraged him to get up and out of his room in between therapy.
The doctor also ordered home PT and OT to ensure that he could deal with the real world.
Medicare only pays for 100 days. After 100 days its private pay. I think you can appeal if discharging within the 100 days, but Medicare only pays 100 days.
The first 20 days Medicare picks up 100%. The 21st to 100 days 50%. The other 50% maybe paid by the secondary insurance or private pay. In my experience there is usually a balance owing of $150. Which amounts up to 12,000 after 100 day stay. You are not guaranteed 100 days. If you reach a plateau and its determined that therapy will no longer help Medicare not the rehab, will have you discharged. Rehab reports to Medicare the persons progress.
I have never received anything in writing about termination of services. I was just told Mom was being discharged on a certain day. Discharge papers are usually signed at day of discharge and a copy given then. It should have been explained at time of admittance how the billing process works.
Unless this family member wants to pay privately, which is expensive, like 10k or more a month, then the facility has to discharge. There comes a time when no amount of therapy is going to help. I would say that with all the appeals made, it must have been determined that Medicare was correct in discontinuing services.
The only thing ur Sister can do is pay the SNF privately and that cost money. Bring him home and see if Medicare will pay for a homecare facility to come there. If not, I think u have to wait so many days and be reevaluated for therapy.
Maybe he can have out patient therapy? But that may come out of his pocket.
How can I say this, ur sister is too emotional? She needs to except what she is being told in reference to Medicare and her secondary insurance. They pay what they pay and that is it. So what are her options:
Pay Privately
See if he qualifies for home therapy
See if he can get outpatient therapy.
Talk to the Social Worker at the SNF.
So sorry she is going thru this.
The Government limitations, and the charting of those doing the actual care and training all comes together into "discharge time". Not certain there is a whole lot we can do about it. Not even certain we can actually understand it all.
My Mom had a major head injury when she fell at her home. From the hospital she went to live in a Rehab facility but after 20 some days Rehab just could not help Mom with physical therapy as Mom could no understand what was going on, thus her brain could no longer figure out how to walk :( This Rehab also had a Long-Term-Care facility, so my Mom was transferred to that unit where she stayed until she passed. It cost Dad $12k per month. Major sticker shock.
My Mom's Rehab facility had no cost as Medicare paid for those first 20 days. And it no longer made sense to have Rehab extend her stay as she was at the same level as she was when she arrived there.
The family may feel the person needs more therapy but there comes a point where therapy just won't fix the problem. In rehab for 3 months can be very depressing.
If your loved one is able to progress further then you need to get them moved asap to ensure insurance will continue coverage until it is determined if there is progress that can be made.
I had to find the facility, then I had to stand over the current facility to do what they needed to do for the transfer. It was frustrating, but you have to do it if you think better care will help your loved one improve.
If he is nearing the 100 days, the family is going to have to decide what to do, he can't stay in SNF indefinitely, it is not covered. If his home will not accommodate him in his current situation then other plans need to be made.
Has your sister contacted the insurance to find out if he could transfer to in patient physical therapy that is not a SNF?
It sounds like she expects him to be 100% before he is discharged and that is unlikely.
I would contact an attorney and get started on a malpractice suit, I am not a believer of coincidence. The odds that the surgery had something to do with this are great, the hospital saying nope is of course standard procedure.
In the mean time your sister needs to figure out where she is going to place husband if he can't go home. She can move or she can find a facility that will likely be self pay. A certified elder law attorney can help her plan and apply for aid so she is not left penniless.
She has just under 2 weeks, help her get busy.
I would hire an attorney to get the diagnosis straightened out to ensure that he can receive the proper care.
I would have the attorney demand that the offending facility reimburse Medicare so BIL can receive care at no cost to him or Medicare because of their dereliction of care.
The sad fact is that medical errors are the 3rd leading cause of death in the USA. This is a perfect example of how it can happen and the arrogance of so called professional medical personnel unwillingness to take responsibility and say, oh my we made a mistake. They play god and start believing their own delusions.
Find an attorney that is well versed in Medicare, www.nelf.org can help you find a certified elder law attorney in your area to get this mess straightened out.
How is your sister doing? Less combative and letting you help more? Does she have a plan for the 10 or so days?