Rehabilitation center Vs Skilled Nursing. What is the difference?

From this california sunday story:

According to court documents, Life Care therapists “canvassed the facility looking for residents they could provide therapy to in order to increase billing.” Sometimes, this resulted in old, sick people receiving needless rehab sessions up to seven or eight times in a single day. According to the Justice Department complaint, one resident who could not walk was allegedly carried up and down the hallway so that the nursing home could bill Medicare for walking therapy. A 92-year-old man who was dying of metastatic cancer was allegedly given 48 minutes of physical therapy, 47 minutes of occupational therapy, and 30 minutes of speech therapy two days before he died, despite the fact that “he was spitting out blood.” At one Life Care facility in Florida, the entire rehab staff had signed a letter declaring that they had “been encouraged to maximize reimbursement even when clinically inappropriate.”

Bad right? But also, it shows a motive to provide rehab because of $$$, especially if everyone is on board.

The story is mostly about the first SNF that got covid, but is pretty interesting in how dual NHs and rehabs work. Not ideal, for sure, but it seems they have an imperative to provide the rehab. https://story.californiasunday.com/covid-life-care-center-kirkland-washington/

Call her insurance company and ask for guidance.

Yeah, advantage plan is a great marketing tool. More like disadvantage.

The rehab should have told you before accepting her that the insurance company would not cover the stay. If she doesn't have the money, she doesn't have the money.

I would get her moved if the insurance company won't pay and get her in a facility that they will cover.

Thanks Peggy. However, we want to keep my mom in the rehab center but we feel like they are pushing my mom out. We want her to stay for at least 20 days but not at $500/day due denied coverage.

Kok, how was it that mom entered rehab? Did she have a "qualifying 3 day hospital admission?

Go back to the discharge planners at the hospital and ask if they can understand why rehab isn't being covered.

Is it that mom isn't particioating in therapy?

You need to ask for the specific reason that she is being discharged.

Call the Ombudsman and ask for their help in understanding what is going on.

Ask the rehab center to show you the denial letter.

You and an associate from the rehab center's business office should call Aetna together to find out why she is being denied.

Getting a copy of the preauthorization woukd also be helpful.

A notice of who the Ombudsman for the facility is should be posted prominently in the lobby of the facility. The Ombudsman is a person who helps resolve disputes at LTC facilities.

Your problem maybe the Medicare Advantage. Medicare contracts out to them. They are suppose to cover everything that A&B covers but my daughter says they don't. She is a wound care nurse and says straight Medicare covers bandages but the MAs she works with don't. So its an out-of-pocket for her patients.

I have never dealt with a MA and refuse to have it. So I am explaining straight Medicare here.

Rehab comes into the picture when a person has been hospitalized for at least 3 days. Medicare covers the first 20 days 100%, 21 to 100 days 50%. The balance after 20 days is out of pocket or your supplimental pays partially, fully or not at all. The 100 days are not a guarantee. If a person has been found to have progressed as far as they can or just can't do the therapy, Medicare will have them discharged.

You are dealing with a Medicare Advantage. They should be following Medicare rules. You need to call them and find out why they denied coverage since they originally OKd it with the hospital.

Skilled Nursing is long-term. Medicare does not pay for skilled nursing. I don't think your problem is with the facility its with your insurance. If Mom does not want to privately pay for her therapy, have her discharged. They cannot make her stay. You may want to see if her insurance will cover "in home" therapy if ordered by a doctor.

You may want to ask the MA if they refused payment because the Rehab is not in their Network. With straight Medicare you can go to any facility that excepts Medicare. With an MA, you have to choose from their providers.

Please read up on MAs. Mom should have a booklet saying what is covered by her MA. Yes, you may get lower copays and deductables. Maybe some advantages you don't get with Medicare but it may not be the right plan for Mom. I hate when the advertisements "Medicare advantages you are not receiving". Its because straight Medicare does not offer those advantages. I have noticed they have revamped the old commercials to have "Medicare Advantage" for a split second in the commercial. The newer commercials say Medicare Advantage. It surprises me that Medicare allows them to use the name the way they do. Its very misleading.

Open enrollment is over for this year. You may want to talk to someone at your County Office of Aging and see of you can sit down with someone and find out about the different MAs and compare to straight Medicare. Mom may be better with straight Medicare and a supplimental which picks up the 20% Medicare doesn't pay.

There are lots of people who are in skilled nursing for the long haul (stroke patients who needed to be fed, cathetered, etc.), but my experience with the skilled nursing place where my mom was for a while was that there were also people there rehabbing from things like hip replacement surgery.

What Mom's skilled nursing place wasn't authorized to do was IVs. I don't know if that's the norm for all SN facilities, but when my mother was in the hospital for an infection, she was later sent to a rehab hospital to finish the IV antibiotics they'd started in the regular hospital rather than a skilled nursing facility.

Medicare coverage for rehab has to be approved, and many things are dependent on needs/etc. You will need to discuss with the resident Social Worker at rehab to find out why things are not being covered. It may have to do with rehab being too soon after coverage of something else in another rehab or SNF.
As to the difference there are MANY. Rehab is just that, rehabilitation, meaning getting back on ones feet and able to do activities of daily living. So it would involve physical therapy daily, occupational therapy, any other specialty therapies that are/might be needed such as speech therapy, would include activities of daily living and measuring progress toward homegoing and discharge planning for inhome needs, and etc.
Skilled nursing is basically because a person doesn't any longer need/cannot benefit from acute hospital care, but DOES need just that, SKILLED NURSING care. That may be needed for any number of reasons, one being wound or decubitus care, suctioning, etc. Something that is done by skilled and trained caregivers.
That is rather a basic overview but as to an individual case you are dealing with individual situation and must check directly with insurance and medicare. The Social Workers can help you here.

In my city, there are rehabilitation facilities, they tend to be for younger people that can do upwards of 6 hours of rehabilitation daily. They were not covered at all by my dads advantage plan.

So he had to get his rehabilitation at a skilled nursing facility. This is a facility that has rehab, assisted living, memory care and long term care (NH). I think this is pretty common throughout the west.

From what I have learned being on the forum what a facility calls itself doesn't mean much, because it varies tremendously from facility to facility and region to region.

Focus on a facility that will give her daily rehab, for several hours and one that her insurance will cover.

AlvaDeer has spot on information. Many people who have been in healthcare will stay with traditional Medicare and a supplemental insurance for this very reason. the Advantage Medicare programs work very well........... when you are sick but depending on the one you chose they can get rather expensive when you are ill - $50 copay for a specialist etc. Of course for people with limited income ... it may be all they can afford. As an Admissions person, I have seen them deny for further stay a person who clearly was not really ready for discharge after only 5 days of PT (she was non weigh bearing even though participating in PT), lived on the second floor of a non elevator building and had no one to help her at home for that evening! My NH appealed their decision and was denied at 4:57 pm. No one in their office would pick up the phone after that. Luckily, I worked at a good NH with a caring administrator so we ate the cost of keeping her another day until her son could get home health and even paid for her transport in an ambulance (their staff would stretcher her up the stairs. regular transport could not)!
Yes MAs have to offer the same services as traditional Medicare but they can set the price and the time length they will offer them. They routinely want a report on PT progress and participation in 4-5 days (many of my residents where still figuring out where they were on day 3 and just willing to put some real effort into PT on day 4). As long as a person needs PT,OT or speech therapy, traditional Medicare will fully pay their rehab expenses in a certified Medicare facility; in 2022 after day 21, should rehab or skilled nursing needs continue, the patient is responsible for $371/day and Medicare will pay the balance. If you have a secondary insurance, they will pay the $371/day. Secondary insurance is a wonderful thing but it is not cheap. Much of it is "attained age" issued which means the cost increases as you age even if you don't develop "age related" issues. Mine just went to about $260.00/month (which is why a lot of retired folks can't afford it ) .

You will need to get on the phone and type emails and get a notebook for all the information (and confusing information) you will get. Good Luck and keep us updated please. We all learn a lot from every question that get asked.

Now even Medicare's as well as MA's willingness to pay depends on a number of factors:
Was there a qualifying 3 night admission to an acute care hospital prior to admission to PT?
Has there been an admission to rehab or hospital within the current benefit period?

Many skilled nursing facilities also have rehab units. Medicare or her MA will have to determine based on an MD's recommendation if she is in need of skilled nursing (usually IV's, wound care, O2, etc.); depending on what the MD says she may need only PT and not skilled nursing so would not be eligible for a transfer to a skilled nursing facility.

The Medicare enrollment period just ended but you might contact the local Office on Aging or your Ombudsman (that's the person that advocates for residents of rehab, nursing and memory care facilities to see if there is anything you can do but remember .... even with Medicare after day 20.;.. if additional rehab or skilled nursing is needed it will cost $371/da (which is a bit less than the $500/day you mentioned