Knowing Your Medicare Rights

My new client was distraught.  His wife had been hospitalized, and then moved to a skilled nursing facility, so she could receive treatment for a serious pressure wound.  She was completely motivated to participate in physical therapy, so that she could get back on her feet when it healed, but at the moment, the pain prevented her from participating.  However, she was eager to engage in therapy to increase her upper body strength, so she would be able t transfer from bed to wheelchair until her wound healed and she could work on strengthening her lower body, too.

Nevertheless, about 80 days into her skilled nursing stay, her husband was being told that she would be discharged. Because she had refused physical therapy, her stay was now considered custodial, so would no longer be covered by Medicare. (Medicare will cover medically necessary care, following a hospital stay, in a skilled nursing or rehab facility for up to 100 days per benefit period.)

Our client had actually come to us for assistance with a Medicaid application, to assist with the cost of that custodial care.  However, because of the excellent questions that my Care Coordinator asked, we realized we could help assure that his wife could continue to receive the skilled care to which she was entitled for 20 more days.

If a skilled nursing facility believes that care is no longer medically necessary, they are required to provide written notice to a responsible party. The notice must follow a specific format, and include the instructions for appealing the decision.  In this case, my client had received only a verbal notice.  When he did not respond, the facility put the written notice by his wife’s bedside (conveniently, right after my client had left for the day), even though they had required my client, as her POA, to sign all other legal documents.  With our direction, our client said that he needed to receive that written notice, either directly to his hands or by mail to the address on file.  While the director handed it to him on his next visit, his insistence that the facility follow the rules had given my client’s wife 3 more days in the facility.

My client received the notice and called the number required to appeal (this call MUST take place by noon the following day, whether it be Saturday, Sunday, Thanksgiving or Christmas), and was given a case number.  Again, with our direction, our client reminded the facility that his wife could not be discharged until the appeal was resolved.

At this juncture, the appeal process involves taking my client’s statement and reviewing the medical records.  It did not take long for Medicare to agree with my client that skilled care remained medically necessary for his wife for the full 100 days for which Medicare will provide payment. Not only did the patient suffer from a severe wound that required regular treatment, but she was absolutely willing to participate in whatever physical therapy she was strong enough to handle.  The only way that her stay could be considered custodial only was if the facility was declining to provide the care that the patient both needed, and was requesting.

20 more days may not seem like much. But in this case, my client’s wife could continue to receive proper wound care and therapy to maximize her upper body strength, while her husband had a few more weeks to research and secure an appropriate facility for her next step.

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