Follow
Share
This question has been closed for answers. Ask a New Question.
Find Care & Housing
igloo572's response implies that the resident does not need to show progress during the first 20 days of Medicare coverage. Please allow me to clarify. Assuming that the resident's stay in the SNF is only covered because the resident is participating in daily therapy and there is no "skilled" nursing care required, continued Medicare Part A coverage can only be legitimately offered if after the first week if the resident is showing progress OR the staff can justify why they think that the resident's response to the therapy program may change in a few days, due to an anticipated improvement to the resident's overall health or energy level, etc. It may be justifiable to allow someone who is not showing definite progress in therapy up to two weeks in order to try different approaches, changing time of treatment to align with observed energy levels, etc., but to go more than two weeks could be deemed fraudulent.
Helpful Answer (0)
Report

Medicare covers first 20/21 days. The following days up to day 100 will totally depend on their "progressing" sufficiently within their insurance guidelines.

If they got discharged from the hospital to a NH for rehab after a fall and breaking a hip. Which is número uno reason for advanced elderly entry into a NH. They need to get to & do their PT & /or OT and show consistent "progress". For family, they really need to do whatever to encourage and help their elder get into their rehab program and get positive progress reports. If the elder refuses to go to therapy (which they can do), or refuses to even try to do any of the exercises, or allow for measurements to be taken, they will be off the rehab benefit in short order. Really do whatever you can to get them to co-operate with rehab.
Helpful Answer (0)
Report

You are correct that the key to determining whether or not Medicare will pay is the IMPROVING condition of the patient (resident). As noted above, Medicare copays are determined by the specific Medicare plan the patient has opted into. "Traditional " Medicare has no copays for the first 20 days, but "Medicare Advantage" (HMOs) may have a copay from day one. The maximum allotment of Skilled Nursing care days for each "spell of illness" is 100 days, BUT in my 30 plus yrs in a SNF, the typical patient would "plateau" well before this time limit. If the patient is enrolled in a Medicare Advantage program, there will be a case manager assigned to track the patient's progress, usually on a weekly basis, to ensure that there is not a misuse of Medicare days beyond the time that it becomes evident that more therapy will not improve the patient's function. This decision is made by facility staff for traditional Medicare coverage, but this does not mean that the staff want to cut skilled services. (Medicare still reimburses the facility at a higher rate than almost any other payer, so it would hurt the facility to issue the "cut letter" one day sooner than justified by the resident's progress, BUT the facility also does not want to get into fraudulent practices by providing skilled services beyond what can be justified.) Medicare guidelines require that at least weekly progress be documented by the treating therapist(s). This becomes problematic when either the patient is not able to participate in therapy (uncontrolled pain, lack of motivation, unable to understand and follow instructions, etc.) or refuses to participate, which actually happens more frequently than you would think.
The family (or resident) can appeal the decision by either the case manager or facility and this needs to be done IMMEDIATELY upon notification of services being cut. The case is then referred to "peer review" to see if the correct decision has been reached. Several years ago almost 100% of appeals ruled to reverse the decision but that is not the case now.
It behooves the family to keep in contact with the therapy staff to get a better picture of the patient's progress, keeping in mind that HIPAA may prevent access to the info if the family member is not designated by the patient to receive this "protected health info". Please also keep in mind that the staff are not the enemy; 99% are truly dedicated to the patients they serve.
Helpful Answer (1)
Report

That's about right, but a lot depends on your insurance. For mom it was $100 a day from day one. Full pay after 100 days.
Helpful Answer (1)
Report

It's my understanding that Medicare will pay for 21 days as long as the patient is improving, and if the patient needs more rehab, then for the next 100 days Medicare will pay part and the patient's secondary insurance will pay the other part.

I hope other writers will jump in here in case that had changed.
Helpful Answer (1)
Report

This question has been closed for answers. Ask a New Question.