Wife with Alzheimers fell and broke her leg. It is so close to replacement knee that it cannot be repaired. Treatment is to keep off leg for 2 months and then see if walking with assist is possible. She was transferred to memory care/rehab facility. Medicare paid for 2 weeks and then denied coverage, allowing that it might start again when walking is possible.
The other thing is we had a supplement plan with AARP that kicked in to help with rehab. Medicare only covers a certain period of time, then if you have a supplement or even a state additive (she had one in CT that helped her stay in rehab longer after recovering from a broken neck and broken pelvic bone). The state gave her a few extra days (10 days I think) because she was on state assistance and that gave us the time it took to give her to really start being able to be mobile. They were concerned as we had there stairs to the front entrance at that time so she was going from bed bound, to wheelchair bound, to walker using to finally staircase climbing. She did amazing I must admit but that was a skill she needed to learn and medicare's time frame had ended and AARP had ended as well (broken necks are tough to heal from and she still even came home with a brace on for a while) so the state was able to give us a boost of 10 days so she came home ready and able to take on the world. She was an addict to pain killers and I had to learn how to ween someone off pain killers (terrible terrible experience but not for this question).
I hope you are able to get the help your wife needs.
I'm surprised the department store didn't offer to cover some of your mother's expenses, even if they weren't at fault. Sometimes good will is more important, but not always.
I personally think Medicare needs to be simplified so the average lay person can navigate the system.
Also, it helps to be tech savvy to navigate the MyMedicare.gov site. The other weird thing I discovered is that Medicare and the Treasury Dept do not share records (other than the debt) and forces people to start from scratch with an additional set of user names, passwords, authorized rep security clearances - and they do not send the previous appeals records - crazy right?
Get advice from knowledgeable nurses and social workers (insurance adjusters may not be the best advisers). The system is beaurocratic, but if you learn the rules- fair.
However, the therapist assigned (after we complained about the first one who claimed she wasn't cooperating), found ways to provide PT anyway. The facility had a bed which could be raised and lowered. Mom sat on it and performed PT with her good leg, and possibly with the broken leg - I'm just not sure whether she did sitting exercises for her broken leg - this was way back in 1999.
Check with the doctor who performed the surgery and ask if your wife can do PT with the leg, on a non weight bearing status, or if she can do PT with her arms and other leg in the interim to keep them from atrophying.
I think the therapist who made the decision and passed it along to the admins and then to Medicare isn't thinking as creatively as she could be.
Or ask the doctor for a script for home therapy, to last until your wife can bear weight on that leg.
I did challenge Medicare on another issue, went to the second level of appeal but it was abandoned by Medicare. No final response. Medicare didn't even have the professional responsibility to respond after I appealed to that second level.
In the meantime, the hospital gave up the claim. This was a different situation though.
DON'T take this "laying down." Fight back; get a elder care attorney who's proficient in challenging Medicare decisions. If you need help in finding one, post back.
do a search for "medicareadvocacy.org/jimmo-v-sebelius-federal-settlement-invalidated-medicare-improvement-requirement/"
You need to still be aware of the medicare hundred day limit and prepare for that eventuality.
From the article:
"Patricia Dudek, an elder law and disability law lawyer in suburban Detroit who represented the Kirbys in their appeal, started printing out relevant sections of the settlement agreement to show nursing home and home care administrators that the improvement standard was 'an old wives’ tale'."
AgingCare doesn't always allow "dot com" links to remain, so if the link I provided is removed, you still should be able to search online and find the article by the title and date I indicated above.
Here is the essence of the article:
What matters, as the 2013 settlement of a class-action lawsuit specified, is maintenance. Medicare must cover skilled care and therapy when they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.”
A bit of background: Because the Centers for Medicare and Medicaid Services doesn’t publish statistics on why claims were denied, nobody knows how many millions of beneficiaries have been wrongly told that Medicare can’t cover continued services because the patients failed to improve.
But providers invoked the improvement standard so frequently that “one way or another, most people who had coverage denied were affected,” said Gill Deford, litigation director of the Center for Medicare Advocacy, a nonprofit legal organization.
Though never part of Medicare regulations, the improvement standard was written into the C.M.S. manuals that providers and claims administrators relied on. “It was a policy they followed for 30 years,” Mr. Deford said.
Patricia Dudek, an elder law and disability law lawyer in suburban Detroit who represented the Kirbys in their appeal, started printing out relevant sections of the settlement agreement to show nursing home and home care administrators that the improvement standard was “an old wives’ tale.”
Older patients with chronic and progressive diseases — dementia, Parkinson’s, heart failure — are particularly vulnerable to that now-discredited criterion. They’re unlikely to improve over time.
Yet therapy might help them stave off decline and hold on to their ability to function a while longer. Edwina Kirby, for instance, used a wheelchair, but hoped to be able to walk the eight steps into her bathroom at home.
By early this year, however, the Center for Medicare Advocacy was hearing from many sources that despite the settlement, providers and the contractors reviewing Medicare claims were still denying coverage when beneficiaries didn’t demonstrate improvement.
The Centers for Medicare and Medicaid Services showed no inclination to take further steps, so the plaintiffs’ lawyers went back to court, seeking enforcement of the agreement. The federal judge in Vermont who oversees the settlement ruled in August that C.M.S. didn’t have to further revise its manuals, but did have to mount a better educational campaign.
Of course, patients and families have the same right to appeal coverage denials that they’ve always had. (A notice to this effect is buried somewhere in the paperwork they sign.) They also have the same odds of prevailing they’ve always had: very low, said Judith Stein, the executive director of the Center for Medicare Advocacy.
Patients generally have 72 hours to appeal, a process that involves seeking a “redetermination” and then, if that fails, a “reconsideration.” If families go all the way to a hearing before an administrative law judge, Ms. Stein said, they have a good shot.
But most families don’t persevere, in part because they can’t afford to pay for care while the appeal proceeds. (If they do spend their own money, though, they can appeal for reimbursement.)
PLEASE READ THE ENTIRE ARTICLE AND FOLLOW ALL LINKS FOR COMPLETE INFORMATION.
Also...the Medicare supplemental policies only cover what Medicare has approved... they pay the difference between what Medicare paid and the total bill. If Medicare denies...supplemental does not pay.
So, the facility has reported the failure to improve. That is the basis of the denial.