What to do if insurance is refusing to pay for rehab stay at nursing home?

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Patient was brought to the hospital after having fall in her apartment. She spent close to two days on the floor before she was discovered. She has since been discharged from the hospital to a nursing home for rehabilitation. After only a week and a half the insurance has informed us that they will no longer pay for her care.

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Is the patient a Medicare beneficiary? Aging care.com has several articles on the issues that arise when a nursing home says the resident can no longer benefit from rehabilitation:

https://www.agingcare.com/articles/get-medicare-to-pay-for-nursing-home-179738.htm

Whether the patient is covered by Medicare, or a private insurance plan, a geriatric care manager could help you get the facts and document the medical needs. Time is of the essence in preparing a response to the nursing home notice.
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It also may have to do with whether she was admitted in-patient or just under observation.
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Assuming she has Medicare, I believe the requirement is a 3 day stay in a hospital before discharge to a rehab facility in order for Medicare to pay.

If this person has a different insurance carrier, you'll need to (a) ascertain the reason why they're refusing to pay, and (b) contact them directly to get more information and find out if there's any way to appeal their decision, as well as get them to pay.

Medicare, e.g., won't pay if someone refuses to participate in therapy. Is that a possibility?

You should also talk to the admins at the facility to find out what's going on with the insurance company's refusal.

Good luck - this is not a time when an injured person recovering from a fall needs to be hassled by an insurance carrier.
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What is the reason the insurance company is giving for denial of this clain? Have you discussed this with the social worker at the rehab?
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I forgot to add that you'll likely need this friend to sign a HIPAA authorization to give to both the rehab facility and the insurance company to get information on their decision.
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Vpatrick, I hope you come back and let us know what's going on. Your poor friend!!
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Patrick, if your friend does have to go home, she can contact the doctor who performed the surgery and ask for a script for home care. That would provide nursing, PT, OT and could provide a home health aide.

It just occurred to me that with a HIPAA authorization, you could also contact the hospital discharge planner, even though your friend has been discharged from the hospital, and ask (a) about other rehab facilities that might take her and/or (b) guidance on what to do.

Discharge planners are supposed to verify coverage prior to discharge for rehab, so apparently something changed after your friend was discharged from the hospital and during the first days of her stay at the rehab facility. The issue is to find out what the change was and how to correct it or work around it.
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Linda, that's a good point. I was assuming that she had surgery and more than a few days of hospital care for stabilization, but that might not have been the case.

We need to know more about the situation.
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