My MIL had a long hospital stay due to a brain infection. Prior to she was 100% independent. She went into a rehab center with very limited ability and is now sitting up and eating after 2 weeks. She still requires assistance for everything else. Her Medicare is denying her the full 100 day stay despite her still being bed ridden and having a massive bed sore that requires specialized care and a scheduled follow up surgery. The Rehab center has been asking us about permanent placement since day 1 of her arrival. She has now lost her appeal (filed by the rehab caseworker) and the facility is saying we can either put her in long term care or would be billed thousands if we loose the second appeal, or discharge although she is mostly dependent. Our hope is she will be more independent with the proper care. Is this a common tactic used to force patients into permanent placement? She has only received 2 weeks of Rehab and her medicare states she should get 100 skilled days as long as it's medically necessary, she is showing improvement, and that must be proved with the proper documentation. Do facilities weaponize insurance denials to liquidate patient's assets?
I’m with the others that whatever TBI she had is way more intensive and involved than what you as her family realize. This may be hard for you and your family to accept. NH has to know what her long term care placement will be as they cannot continue to have her now as a custodial care resident without a decision made by family as to how payment will be forthcoming as Medicare rehab patient care has stopped and Medicare does not pay for custodial care. Right now while it’s in appeal, NH cannot force a payment but once the 2nd appeal determination is turned down, they can and will seek to place financial & legally binding responsibility onto someone or they will find a way to get her out of their NH. If she has no resources, then y’all need to speak with the NH asap on her filing for LTC Medicaid & becoming Medicaid Pending if this Nh participates. Or find a NH that does & will.
Right now for most States LTC Medicaid, its income max of $2829 and nonexempt asset max of 2K. If over assets, then by & large end up doing a legit “spend down” by private pay for her care till eligible for LTC Medicaid. Liquidating assets by private paying for care is what folks flat use do to eventually become eligible for LTC Medicaid. The NH & the PT are not in collusion on this.
Otherwise if family does not pay or take her into one of their homes, what tends to happen is a NH will find a reason to call EMS to take her to the ER and then refuse to take her back. Then the hospital discharge planner will then contact you to come and get your mom. Beyond stressful for all, please try not to let things get to this type of situation.
Your mom’s situation is a bit different as a surgery is planned. & what I’ll guess this Nh will likely do is try to get her next scheduled surgery to move up so she exits asap.
Please realize the bill she is accruing for her now custodial room&board still will exist. Nh will seek to get someone to pay. That she had an unpaid bill at this NH will appear should a future NH run a credit check.
fwiw I’m in PT right now as a follow up to getting Euflexxa shots on one of my knees. PT is one I’ve seen before for post surgery rehab in the b4 Covid times. It’s a free standing rehab center with PT & OTs. Anyways they do not take Medicare post hospitalization rehab as Medicare requires reporting on a schedule into the Medicare online portal for progress in order for coverage to be in force with progress determinations within 24 -48 hrs. This place does a weekly update approach, more sports medicine rehab guys. I’m mentioning all this as what probably happened for your mom was that every day for those initial 2 weeks ended up with the PT / OT filing their required timely Medicare notes as “insufficient progress” or “non-compliant for care” and rehab had to stop. There unfortunately is nothing to appeal as her chart shows no measurable “progress”. It is what it is.
Is she making progress if she is?
If she is not participating and if she is not making progress Medicare will not continue to pay for rehab.
How are we supposed to answer this question? You are insinuating that a rehab facility is in collusion with a LTC facility? The LTC facility gets "customers" but many require Medicaid, which doesn't reimurse them much. Unless it is privately owned, then only the "corporation" benefits. And they'd need to do their own bookkeeping/accounting to cover it up. FYI LTC facilities have no shortage of "customers"...
How would the rehab facility benefit? Through kickbacks? Again, unless it is privately owned, then only the "corporation" (and not individuals) benefit. An audit would flush this out.
Medicare Advantages are contracted out by Medicare and must follow parts A & B guidelines. But they are a b***h to work with.
Someone is saying Mom is as far as they can take her and Medicare agrees. There is no getting better because the infection did damage. Does she see a neurologist? Maybe she needs tests run to see where she is brain function wise. In the meantime, if there is no one to care for her at home, maybe place her for now in a SNF or AL. See if she can continue to have therapy. My Mom had it at her AL as an "in home" thing.
If moving her to long-term-care (perhaps under Medicaid?) is an option, is there a reason to reject it? You can always take her out of LTC.
You have appealed.
It has been denied.
There is no one anywhere who wants to think that progress cannot be made by their senior with exemplary care, but the fact is that is often the truth, and that Medicare will not cover this care "just in case" progress can be made.
You need a long discussion with MD and possible brain scans should be done to assess the current known damage to your MIL's brain so that decision for long term care can be made. You need also to know that wound care can be done in-facility.
You need to know where this decubitus happened and be certain that it was reported to the state as is necessary in almost every state.
I am so sorry. You may be looking at palliative and comfort care, possibly even hospice care soon. It does appear that the damage to your MIL's brain was severe. I know that's hard to accept. I wish you all the best.
My mom’s Medicare paid for her entire 100 days in rehab. Even though my mom was in her 90’s she was still able to do her exercises. Mom had Parkinson’s disease.
Also, was she able to fully participate in the exercises? Rehab is a pretty rigorous program. If she wasn’t able to keep up, they won’t continue working with her.
Has your mom ever done a home health program? If so, was she able to progress with that?
Home health care is good. My mom’s doctor ordered it for her and she did well with it. If she wouldn’t have shown any improvement, Medicare would not have paid for it.
What are they doing to help heal her bedsore? That has to be treated. Is she experiencing any pain that is preventing her from doing her exercises?
What exactly did they say to you? Did you have a meeting with the staff? Please schedule one if you didn’t.
Best wishes to you and your family.