Anything that can be done if the SNF has terminated much needed Physical Therapy?

Your family member is in a SNF, and expected to remain there. What for?

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?

I think you are correct. I work in long term care. Near the end of the medicare 100 covered skilled days, you will receive a letter of Non-coverage with an end date. This is really not negotiable and skilled services must end, including therapy, unless there is another insurance that would kick in at that point for skilled care, however, most will not kick in after the 100 medicare days. If they stopped therapy before the 100 days, it means that the patient was not likely progressing at a rate that warranted continued therapy. This does not necessarily mean that you have to be discharged at that point, it just means that therapy is no longer justified, and they can stay to the 100 days if there are other skilled needs. If there is medicaid in place, the patient can stay past the 100 days, but will not received skilled therapy since medicaid does not pay for that....only the custodial level room and board. If the patient is not ready to go home and does not have medicaid, then this is the point when they should spend down their assets and pay the facility privately until they qualify for medicaid. If the patient does not have medicaid and does not intend to private pay and has run out of medi-care days, then yes, it's time to be discharged and you would receive a separate notice of discharge. There is not really anything to appeal. Be careful, if you have been issued a discharge date, and you appeal it and the discharge is upheld, then the patient could be held responsible to pay for the days between the original date of discharge and the date that the appeal was denied. The hardest thing for families to to accept when therapy needs to end. Trust me, if the facility could justify it, they would continue therapy up to the 100 days....why wouldn't they? They would get paid more from medi-care. If a facility continued to try to give therapy to a patient who did not meet the medi-care criteria for therapy, they would really be penalized if they were ever audited. I hope it works out for you

It is all so complicated that I don't know how anyone walks through it understanding it. My bro was in Rehab, not skilled nursing, but seemed to me it depended on A)Medicare allowances B) Supplemental insurance C)what the rehab SAID about progress. When it was known that there was a benign brain tumor sitting on the medulla then there was limited help to be expected from PT. They taught balance exercises and so on and actually made a lot of improvement for him. But after about 3 weeks the PT folks charted that he was at the level they could get him to ultimately, and no further improvement could be expected through PT. As he was already doing well with OT (you know, making the peanut butter sandwiches and so on, Activity of Daily Living as thy call it), that made him eligible for discharge. Turns out the doctor would prefer him to be in rehab until followup MRI planned a month after being admitted. So they kind of "fudged" and as he had still an open head wound from an accident, they were able to get him another week on "wound care".
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.

You need to understand the system.

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.

Zachary22, may I asked why a family member is in a Skilled Nursing Facility? Or is that person living in a Rehab facility? Did the family member improved with physical therapy?

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.

Just want to say, the Rehab does not determine when a person no longer needs PT/OT...Medicare does. If Medicare says no more rehab, then patient gets discharged. They can be discharged to home on a LTC.

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.

I transferred my dad to a different facility when I felt like he was being treated like a dollar figure and not a human. The new facility gave him way more therapy everyday and it improved his quality of life.

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.

First let me thank everyone that answered my question. It seems that maybe my explanation was not clear. I was trying to keep a very long story to a minimum. I guess I didn’t do a very good job of it.

The family member is my brother-in-law, my sister’s husband. He has Medicare A and B and supplemental insurance through AARP plan F. Coverage runs out on July 20th. He originally went into the local hospital in NJ, as he was unable to move his left leg and could only wiggle his fingers on his left hand, but was still able to lift his arm. This hospital insisted that he had a stroke, it was later determined that this was false. My brother -in-law had spinal surgery done in November of 2018. Supposedly this hospital saw swelling in the neck area that they determined it was caused by the surgery and that the swelling caused the paralysis. He was then moved to the NYC hospital that did the surgery. The NYC hospital determined that the paralysis was not caused by the surgery, confirm no stroke, but never gave a reason for the paralysis. I did forget to mention that he had developed partial paralysis of the diaphragm by this time and was totally paralyzed on his left side and lost some movement in his right leg and lost fine motor skills in his right hand. He was basically given a death sentence. He was placed in the current SNF in NYC.

Once they started giving him physical therapy, he started making amazing progress. As of July 4th, he was able, with assistance, walk 60 feet with a walker. He is able to pull himself to a sitting position in bed and manages to use a slide to transfer to a wheelchair. On July 4th PT ended.

The SNF has verbally informed the family, since May, that coverage was running out, no written document of discharge was ever given. There was no discharge plan ever discussed at any of the meetings and is unable to return home as he still needs the wheelchair and walker, their building has stairs to the building, stairs up to the apartment, and no elevator.

Of course, after the first of these meetings, 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 SNF and that Livanta could do nothing for them, since the SNF dropped the case. Approximately a couple of weeks later the SNF verbally told them that services were ending, 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. In the denial letter Livanta stated that he was admitted into the SNF for “acute on chronic respiratory failure.” No mention was made about paralysis. This letter went on to say “The patient requires minimal to moderate assistance with ADLs and transferring. The patient does not have any skilled nursing needs at this time.” The last meeting was on Monday July 1st. Again, they were not given anything in writing. On July 2nd, the family was finally given a written one-page document. This document stated that it was a notice of 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 today.

It was after contacting the office of the NYC Ombudsman, on July 3rd, that they realized that what they had was a notice of Termination of Services and not a discharge notice. Supposedly, this is a common practice of this particular SNF. They make patients believe that they are being discharged and he keeps filing appeals, that are continually denied. This done to keep the SNF from providing the much-needed Physical Therapy until the Medicare really does run out. If they write a discharge plan, that my sister keeps demanding, they

Zach, I had to stand over the employee that was supposed to do the paperwork, so it sounds like your sister is in a similar situation. She will have to stand over them to get this done.

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.

In my case the date of coverage expiration is correct 7/20. As of 7/4 the SNF terminated my brother-in-law's PT. On 7/3 the day before the termination of PT he walked, with assistance and a walker 60 steps, 20 more than he did on Monday. He was still making progress. Remember, when he entered the SNF he was totally paralyzed on the left side and could not support his weight with the other side, he had to be put into a wheelchair with a hoist.
Livanta's explanation for the termination was due to incorrectly reading his record, incorrectly read or not at all. My sister now has the proof of this, she has a copy of the realese from the hospital and the transfer to the SNF. Livanta's explanation of termination was totally wrong. Is there anything that can be done in the limited amount of time left. There has also been a bit of regression in the 5 days that he has not had PT

Just read ur newest response. I see all the appeals and understand the misdiagnosis but understand that no matter if the person could benefit from more therapy, Medicare only pays for 100 days. Supplements usually go with Medicares findings.

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.

Is this because of the 100 day coverage end or because of "no progress"? If it's 100 days then there's not much you can do. If it's because of "no progress" then fight. As you found, your first appeal will be denied. Your second appeal will probably be denied as well. Your first best hope is the third appeal. The first two are done by another healthcare company. Why would they not side with a fellow healthcare company company? The third appeal is the first appeal with medicare.

I recently had to deal with this myself. I'll write that story when I have time. It greatly irritates me that people still are quoting the "no progress" discharge. As we recently discussed, there's no such thing. I recently ran into someone with decades of experience in healthcare that kept saying that there is "no progress" standard. We discussed it and I suggested he look it up himself. To his credit, he did. He got back to me and told me I was right.

Spread the word. Educate people.

As another option, if he can walk 60 ft with a walker, he could likely do home health PT. It is considered a different level of care and might be covered several times a week. So if he doesn't stay at the SNF, all hope is not lost.

Should have looked up Livanta before. I live in NJ and have never heard of it. I now understand they can help appeal a discharge and Medicare will abide the ruling but...can this happen once the 100 days Medicare allows have been met? I don't think so. From what I have read in the article below, BIL maybe able to get PT out of the SNF but Medicare will not pay for the SNF stay. So now sister has to work with the options she is given. If SIL needs help with his care when he comes home then she will need to hire it. If money is a problem, he may qualify for Medicaid homecare. Or place him in an Assisted living and have therapy come in there. ALs cost 1/2 as much as leaving him in rehab.

https://www.medicareinteractive.org/get-answers/medicare-covered-services/skilled-nursing-facility-snf-services/snf-care-past-100-days

Has anyone put the paperwork from the hospital and the rehab together outlining the discrepancy?

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?

Are you sure that $18K Bill was for July? They don’t bill ahead. Maybe it is an EOB (explanation of benefits) for prior months?
Look over the “bill” again. No one bills that way- the month isn’t even done.
Of he could walk 60 ft he can continue his progress either with home health services (PT/OT) or out patient rehab after discharge.
Thats really messed up about the incorrect diagnosis. You’d have to go back and review their billing codes to make sure they billed correctly. I would ask their billing department for the ICD 10 or CPT codes used and sister or you can look up those codes on the internet to see what they mean.

But otherwise, my guess is they are not going to change the July 20 date. If sister has a new apartment set up for 8/1 she may need to stay in a hotel.