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

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

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?

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.

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.

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.

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.

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.

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?