My mother has been hospitalized 3 times this year alone. I have been her sole caregiver for 3 years, and she is now to a point that I can no longer manage her care at home. Was hoping for a short term rehab stay after this visit to buy some time while waiting on Medicaid approval. Doctor, PT, & OT have all suggested discharge to short term rehab for PT & OT, but insurance has declined. Any guidance would be appreciated!!!
The trouble may be your mothers diagnosis if it requires much attention to medical conditions.
Most rehab facilities are focused on providing PT and OT with the goal of returning the patient to independence or at least self-care. They count on about a 2-3 week stay and have limited diagnostic or treatment capability compared to a general hospital.
Medicare is extremely goal-oriented, where rehab is concerned, and requires quite specific accounting of patient progress. If they felt that they were mostly providing mainly interim nursing care they would quite likely decline coverage.
Have a talk with her physician, explain your problem. Since your Dr. is recommending a "rehab" facility, your best bet might be to see if he will re-write her admitting diagnosis... just a little...not omitting anything, but emphasizing her need to gain strength in some aspects of self care. I'm not assuring you he will be willing or able to do this, or that it will automatically change things, but, coming from the physician it might make all the difference.
Doctor could have even discharged her directly to NH and some will admit with pending Medicaid application.
If you filled out the application, look through the list of items they need for verifications (or review what they asked for). Make sure you send every single thing or app likely to get denied. Take the verifications to your local office and ask to speak to a worker to be sure you brought everything they wanted and ask the worker to document that you did provide everything that was needed and you'd like a call when the application is being worked.
Also, after decades of either no health insurance or lousy, rotten, good for nothing insurance (Kaiser we were forced to pay for because of rip-off Obamacare) when I became eligible for Medicare, I opted for AARP United Healthcare supplement plan G. It does cost me more, but the benefits are great. No co-pays ever, don't need to get referrals, and if I ever needed rehab, it would pay for up to 180 days. If you choose one of these plans at first eligibility, they cannot turn you down and you won't have to be underwritten if you have serious medical problems. I have had months of 2-days a week physical therapy, and did not have to pay for any of it.
pocket for rehab after a long hospital stay. He truly needed in patient rehabilitation. It was very frustrating.
I would try to line up good coverage before you need it. Try to locate a social worker in your area to help you. If you are a church person speak to your pastor, she/he would probably know someone. If not, ask around, use social media like the neighborhood app or Facebook.
Wishing everyone good health
When renewal time comes around, consider returning to regular Medicare and buying Supplemental insurance. It will cost more than an Advantage Plan, but it may serve you better when you need services covered.
A while back I print screened this info so I can't copy and paste. But the article says when an Insurance Company turn something down that should be covered u do this:
Ask for the HIPPA Compliance/Privacy Officer
When you get the officer, you ask for the Credentials of every person accessing your records to make the decision of denial.
The article claims that the decision will probably be reversed because they do not want you to know that the person who denied your claim may be a HS graduate with no medical background.
To file a HIPPA violation u contact
US Office of Civil Rights (OCR.gov)
I avoid any HMO plans after being advice by a well-known hospital when my dad needed surgery. At that time, I was able to remove my parents from their 'plan' as it was at the end of the year and kept their Medicare separate from their supplement plan. We have since not have any problem with either of my parents' medical care needs when i tell the providers that their insurance coverages are separate including my mom's short-term rehabs. The additional cost saved a lot of headaches and at the end of the day it also saved on cost.
Good luck.
if anybody is reading this and you still have a choice between straight Medicare and a advantage plan please do not listen to Joe Nameith. Straight Medicare and a supplement is the way to go.
MAs are to allow what Medicare would under A & B. As I have stated before, my daughter was an office unit manager that fought with them all the time.
In the meantime, as already suggested, file a challenge to the decision.
The patient/caregiver/family can file a complaint with Medicare through 1-800-Medicare or the Medicare ombudsman: https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home
If it is a denial from the MA plan directly, then you need to review the remittance advice to determine why it was denied. MA plans are allowed to put additional restrictions on coverage using proprietary utilization management. Read the fine print of your policy to determine if certain diagnoses or conditions are exempt from coverage.
MA prior authorization has been getting a lot of scrutiny based on an Office of Inspector General Report released in April: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp.
There was recently an article in The NY Times about this report. https://www.google.com/amp/s/www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.amp.html
The report highlighted the use of prior authorization denials that violate the MA plan's own coverage policies and the high rate of appeals success in which the MA plan ultimately overturns its own denial. Appeals timelines can be lengthy and its frustrating to see patients suffer while they wait. But that is the only way to ultimately gain access to care. The prior authorization problem is so bad, Congress is working on bipartisan legislation to reign it in: https://www.congress.gov/bill/117th-congress/house-bill/3173?s=1&r=5.
Even the trade organization representing MA plans realizes the writing is on the wall and they have endorsed this bill: https://www.congress.gov/bill/117th-congress/house-bill/3173?s=1&r=5.
So, in summary:
1. Find out who is denying access to the services- the rehab or home health agency or the MA plan (or both).
2. If its the rehab or agency, complain to Medicare and show them these resources refuting misinterpretation of the payment system.
3. If it's the MA plan appeal, appeal, appeal, appeal!
4. Always get the physician who ordered rehab or home care involved.
5. Contact your members of Congress and encourage them to support H.R. 3173.
MediCARE Advantage Plans absolutely are the devil. They are smoke & mirrors sold to unsuspecting seniors. Silver sneakers my butt….. What is especially galling is that tax dollars are used to support Advantage Plans. Initially the feds paid a % to get them started as a way to do cost containment/ cost efficiencies and fed support was to be phased out. Insurance lobbyists have made sue this hasn’t happened.
In my father’s case, the process involved me getting access to all his therapy reports from the rehab facility, getting the “detailed explanation of Medicare denial” that specifically states their reasoning for denying coverage, and then calling a phone number supplied on the denial form to initiate the appeal. You have until noon of the following day after receiving the denial form to make the phone call. It’s important to have prepared a statement as to why you feel the denial is wrong. Make sure you focus on the doctors’ and therapists’ recommendations for rehab and that she needs a higher level of care than can be provided at home and that it would be unsafe for her to discharge home without rehabilitation (given specific examples of things she cannot do without rehab to get stronger). A decision is made within 3 days. If the decision goes against you, you can file another appeal. I did get to this point in my father’s case because I did not have enough time to get all the necessary documentation. In his case, his Medicare insurance company claimed he was not making progress and declining. Because I had the therapists’ notes, I could directly refute each of their claims with specific data and examples showing that he was making significant progress. Took 14 days to get the decision but it did go in our favor so they had to cover his two months of inpatient rehab therapy (less the copay you are responsible for after 20 days. Fortunately for my family, I am a Speech Therapist so I have a medical background and knew how to read the reports to support our position. Also, keep in mind that the hospital cannot discharge your mother if she is not safe to return home. Get the case worker involved and if needed, find out who your county ombudsman is in your state. Their job is to help mediate between the insurance company and you and your mom. I found them to be very helpful.