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A local hospital is insisting that my grandmother discharge to a skilled nursing facility even though she has met Medicare criteria for inpatient rehab admission. We even have an order from the doctor for discharge to inpatient rehab. We've stated what rehab provider we would like to consult, but the discharge planner has told us that the provider would not accept my grandmother and that the provider is out of my grandmother's network... but my grandmother has Medicare. There is no network. As of today, the rehab provider we prefer still has not been consulted by my grandmother's case manager. Is this hospital operating within CMS guidelines with this type of behavior? What can we or the rehab provider we've chosen do about this. Our preferred rehab provider has explained that they can not become involved in my grandmother's care unless they are called by hospital staff to do so.

Call all the places you are interested in yourself and see what they have to say. Sometimes discharge planners send people to the place that is easiest for them to coordinate and not what is best.
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Reply to dogparkmomma
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When my mom did rehab we were given the opportunity to choose the provider. My mom also has Medicare and a supplemental insurance.

I do not understand why you would not be able to select where you choose to go. I would insist on your first choice.

I would enlist the help of her social worker and her primary doctor if I had to. Have them join forces with you for an added push.

Best wishes to you and your mom.
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Reply to NeedHelpWithMom
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Well? What has happened?
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Reply to Isthisrealyreal
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Sometimes groups of doctors own nursing and rehab facilities.

Stepdad was sent to one of those, as it was recommended by the hospital. The care was awful, so got him out and into another facility, not owned by doctors but by a large corporation. Care was much better, brighter and modernized.
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Reply to gladimhere
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ABSLAN, stand over them and insist that they call. That is what you do.

I am here because you are not providing me with information that makes sense. Call the rehabilitation facility right now and get them moving on getting my loved one set up. Yes, right now, here's the number and the name of the person that you need to speak with. Yes, pick up the phone and call, right now. Or I am happy to get them on the phone, here let's use my cellphone.

That is what you do.
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Reply to Isthisrealyreal
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In my state joint replacement patients commonly go to rehab. Even a neighbor, in his 50's went to rehab following a shoulder replacement, but he was not on Medicare, this was part of a workman's comp.

Stepdad at 84 went to rehab following a hip replacement.
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Reply to gladimhere
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Inpatient rehabilitation hospital care-Examples of common conditions that may qualify you for care in a rehabilitation hospital include stroke, spinal cord injury, and brain injury. You may not qualify for care if, as an example, you are recovering from hip or knee replacement and have no other complicating condition. More information-https://www.medicareinteractive.org/get-answers/medicare-covered-services/inpatient-hospital-services/inpatient-rehabilitation-hospital-care.
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Reply to Labs4me
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Would it matter if your grandma doesn’t have a secondary insurance? Medicare pays 100% but not for the entire stay after 21 days.
Just throwing out a thought.
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JoAnn29 Feb 17, 2020
They only pay 100% for 20 days. 50% 21 to 100 days. Suppliments do matter if u have Medicare Advantage. Whhole different ballpark. This is why I won't have one.
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Just read your response. Call Medicare. Tell them the situation and see what they say.
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Reply to JoAnn29
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If you are dealing with the same person, ask for the supervisor and tell him/her you need an explanation why they are not following thru. I may also get the discharging doctor involved. Call his office and speak at least to his office manager. Be the squeaky wheel.
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Reply to JoAnn29
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Then stand over them and insist that they call. By law you have the right to choose the provider.
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Reply to Isthisrealyreal
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ABSLAN Feb 16, 2020
I think your point is really the question I am getting to... what is the correct course of action? The ordering physician has explained that this facility send patients to skilled care facilities for rehab to decrease the overall cost of care that Medicare holds them responsible for while they try to earn "shared savings". Basically, the smaller the amount spent on the care of patients, the savings is split between this facility and Medicare at the end of the year. So instead of sending my grandmother to the rehab facility she qualifies for, where she will get 15 hours of therapy a week, they want to send her to skilled nursing where the cost is much less, but she may only get 7 hours of therapy a week. He explained that this is the way this hospital is doing business. I know if this is happening to us, it's happening to other patients. It's really not right. Initially, the discharge planner didn't even tell us she qualified for rehab, she just said she needed skilled nursing. It was the doctor who came in later and said he had ordered rehab and explained the difference between true inpatient rehab and skilled nursing admissions.
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I am with Alva here.

If the facility excepts Medicare they might not be in the network for a Medicare Advantage. You need to ask if Mom is on straight Medicare with a supplement or a Medicare Advantage.
Medicare Advantages are HMOs or PPOs. Both work within a network. The difference is PPOs may allow out of network but will pay more if you remain in network.

What u need to ask the Discharge nurse/clerk is what does she mean about network. She maybe under the assumption ur insurance savy (not saying u aren't) and really u have no idea how Moms insurance works.

Believe me with all the different plans out there and all depending on the amt ur willing to pay out monthly its so confusing. My Dads employer made it mandatory for retirees to buy from an exchange. Some of these people were in their 80s. Previously all they did was show their Aetna card and that was it. There was no network. They had no idea what that meant. I did, because my DHs insurance was in network. I had no problem switching Mom. My problem is educating my DH.
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Reply to JoAnn29
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ABSLAN Feb 15, 2020
Thank you. My grandmother has Medicare A and B, no Medicare Advantage plan, no network restrictions.
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Does your grandmother have supplemental insurance. I think that is the network they are speaking of. No, the rehab can not, of course, interfere. That would look like ambulance chasing, because of course this is how they make their living. Your Doctor and the Hospital Social worker are the best ones to answer this question, just not something we could know.
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Reply to AlvaDeer
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ABSLAN Feb 15, 2020
Nope, no supplemental insurance, no network restrictions and have confirmed this with our preferred inpatient rehab provider. It just seems that we aren't being given the option to discharge to inpatient rehab even though criteria has been met. Crazy! I'm having a hard time believing this is all good with CMS. Since when does the patient not get a choice in the discharge plan? I could totally understand if she didn't qualify, if the provider was truly out of network... but nope... none of the above... just crazy to me.
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Did you verify that the chosen provider and the facility that they use accepts Medicare?

Not every inpatient rehabilitation facility accepts Medicare. You should clarify that they do indeed take Medicare and then request the hospital call while you are present. My dad didn't qualify for in patient rehab because he needed help with activities of daily living that they didn't provide.

My dad went to SNF for rehab and had great results. He was in rehab multiple times daily, 6 days a week. He was also encouraged to walk around the facility multiple times a day. He was getting at least 3 hours daily of rehab. He went from being able to transfer from wheelchair to bed to walking the halls.
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Reply to Isthisrealyreal
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ABSLAN Feb 15, 2020
Sure did! The provider confirmed we were all good from a coverage standpoint. The only barrier is the inpatient hospital refusing to consult. She's qualified and met all criteria, is a good candidate... the hospital just isn't giving us the option.
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Skilled nursing is rehab. Rehab is not done in a hospital. Maybe preferred place does not have all the therapies grandma needs?
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Reply to gladimhere
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FloridaDD Feb 15, 2020
IME, the difference is that the hospital wing rehab gives MUCH better rehab, but would not take my mom after she could no longer do 3 hours a DAY of rehab.  When she was younger, she did qualify for the hospital wing rehab (in Atlanta), as did one of my co-workers in NY (really good hospital).   Now my mom is older and cannot do 3 hours of day of rehab and her choice was SNF or we could take her home and PT/OT would come to our home, for about 3 hours week, same as it would be in SNF
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