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My mother frequently falls out of bed. The doctor has ordered a special mattress to prevent her falls. What is shocking is that the nursing home is asking me (her daughter) to pay for it. The mattress is designed to prevent falls. The mattress has cushions that surround the edge of the bed to promote a safe bed environment, without the need for confining side rails. As a back story, it took 6 months for them to order an air mattress when she first arrived to prevent bed sores. Is this legal?

Yes. Some nursing homes, however, will have a vendor and rent beds for physician prescribed equipment. Also, often pay the cost. Ask if you can rent one. The nursing home should have a vendor or know of one. If not, find a medical equipment supplier in your area.
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Reply to SeniorsHelp
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Imho, this is essentially a prescription that is paid for by the patient, aka, resident.
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Reply to Llamalover47
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Yes, it is legal. It's not up to the Nursing Home to pay for a Special Mattress. You should contact the Insurance Company and see why they aren't paying for it when it was ordered by a Dr.
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Reply to bevthegreat
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The issue is not whether the Doctor ordered but whether your mother's insurance covers it. Medicare, Medicaid, or private insurance all have specific guidelines about what they cover. The days of a doctor order being enough have been gone for almost 30 years.
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Reply to MsRandall
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When my Mom was graduationed off hospice after 2 years, the hospital bed with air mattress and special wheelchair were removed by them. Our Dr ordered replacements. The company contacted me explaining what Medicare and supplemental insurance would pay. The mattress was only covered 80% as well as the gel pad for the wheelchair. Her out if pocket was over $150. Now the monthly rental is about $25.
Mom did not fall out of bed and no rails are allowed, but she would get up in the middle of the night to go to the bathroom and collapse to the floor ( she was on a toileting schedule). Unknown to me, they started putting her to sleep in her recliner ( I signed a waiver to have it in her room years earlier). I did not know about this until the new care plan this month. So the hospital bed is just sitting there, but someday, when she is slipping away, she will use it.
Call her insurance company or Medicaid to see what her copays is. And yes, there us a limit to how often equipment is covered.
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Reply to GrandmaC
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If I’m not mistaken, there are schedules for DME ordered & paid by Medicare. So if MediCARE paid for an alternating mattress within the recent past, there may need to be a waiting period to get a different style or upgraded mattress. A fixed perimeter mattress (1-2k) or a bariatric mattress (4-6k) would be upgrades. So the patient has to show that the initial mattress is not sufficient for &/or providing the level of care needed. Her old MD writing an order for a newer type of mattress is great but on its own not it is not enough to get a new one paid for by MediCARE. MediCARE isn’t going to pay for one if the old one is sufficient, not if it makes their life easier or makes it easier for staff, but is medically needed. Could this possibly be what is happening?

What MediCARE does for DME will be what other insurers & Medicaid do for paying for DME.

As others have posted, DME industry has had pattern of shady practices. Price gouging & outright scams over the years. MediCARE has paid out $M’s.
Which has meant that now it takes forever to get approval for DME. Add in that a mattress or wheelchair has a set lifespan of use, so getting a replacement or upgrade easily is kinda impossible if the item still is within its lifespan of use and the persons medical status hasn’t changed significantly. It sounds like it’s only a few months that your mom has her 1st mattress, if so, it’s just not enough time for MediCARE to pay for a newer version.

It was beyond really hard to get MediCARE to cover a newer wheelchair for my cousin w secondary polio, would take months to approve & have paperwork done by his therapists etc and him as to why a newer version would make a difference, yada yada. He had a SNT so had the $ to just buy one & that is what happened. But had SNT not been there, someone would have need to run over his old speciality wheelchair & flatten it in order for mediCARE to ever pay for a newer one.
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Reply to igloo572
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I live in assisted living. A.L. and nursing homes provide basic items, beds, chair, dresser. Anything "special" is always paid for by the families - or the resident. No one but them pays for anything special - ever.
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Reply to Riley2166
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If your mother has any funds, she should pay for the mattress. If not, you have the choice of paying for it or your mother not having that mattress. My mother got a bed sore, so they called and asked me to get her a mattress to try to help,prevent future bed sores. I was glad they called. It felt good to be able to get her something she needed.
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Reply to Mjlarkan
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When you go to a Nursing home all that is covered is your care, Depends, wipes, chux, your prescriptions, your food, therapy if needed, your bed, side table tray, linens, hospital gowns, toiletries, woundcare,etc. But they do not pay for your durable equipment. And Medicare does not pay for everything, nor does a supplimental. Medicare has weird rules. If you get this, they won't pay for that. Yes, shower chairs are one thing they won't cover.

Mom went in with her walker. Yes, they supplied the wheelchair, geri chair and eventually a concaved mattress. I never signed for anything to be ordered so I assume that the items were on hand, left by former residents. We as a loan closet when we got a overrun of donated equipment called around to the homes to see if they could use it and they usually did.

Just because a Doctor writes an order doesn't mean Medicare will cover the cost. I doubt the average Dr. knows what Medicare will and won't pay for. So if the NH is asking that OP supply the mattress its because they don't and it cannot be ordered thru Medicare or secondary insurances. I have found that facilities are very good about doing the ordering if they can get a patient equipment.
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Reply to JoAnn29
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igloo572 Jun 28, 2021
When my mom became bedfast, all her old walking stuff - a really nice & new Hugo, a speciality ordered for petite walker, 4 footed canes - went over to the loan out room at the NH. It was a sight to behold, what a variety!!!. This seems to be standard procedure for a NH. It was nice knowing that another family, who perhaps could not easily afford one, could use moms old Hugo.
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I had my mom with me. She has Alzheimer’s and continue to get worse. I had to put her in AL. I read that if you put a pool noodle on side of bed, under the bed sheet, it’ll help to keep them from falling out of bed.
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Reply to Dragonfly62
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The nursing home should be asking the resident (your mother) to pay for it. If she can't, is it really that shocking they've asked you? Who do you think should? Who pays for the rest of her medications and personal needs?

I agree strongly with Cetude that the reason for asking ought to have been made clear.
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Reply to Countrymouse
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Who pays for her other prescriptions? Also, I presume there was a contract with the NH. See if this eventuality is mentioned in that contract.
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Reply to WVson1
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Medicaid/Medicare has *VERY* strict rules what it will cover. They just don't cover "everything". For example, Medicare will NOT pay for side rails used in bathrooms. They only thing they will cover is a bedside commode. They do not even cover shower chairs. As for Medicaid, what they will cover is determined by the State.

Medicare/Medicaid will NOT cover specialty walkers, such as an upright walker, but only one kind of walker with wheels and no elbow rests.

This is no scam. Her insurance will not cover it. You can call the insurance and verify. The nursing home SHOULD have given a REASON why they won't cover it. Shame on them!
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Reply to cetude
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Side rails are 100% illegal in nursing homes -- they are considered a restraint; in fact, research shows side rails are more dangerous since they can still fall out of bed and get an arm or leg caught in it and have a catastrophic event.

Defined perimeter mattress will not guarantee she will not fall out of bed. They can still crawl over them.

She should be put in a very low bed near the floor. I find it very odd the nursing home does not know how to deal with high-risk fall patients since it is a nursing home.

Causes of frequent falls should be investigated. Any kind of psychotropics or narcotics increase risk for fall substantially due to decreased reflexes. Muscle relaxants, antihistamines, blood pressure medications, and anticonvulsants all too can contribute to falls. Any kind of room clutter, poor lighting, all play their part. Toileting is the most common cause of falls--they need to go to the bathroom, they will want to get up. Toileting should be scheduled.
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Reply to cetude
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Her health insurance should take care of paying for it. Call her insurance company and ask if they will pay for it. If they say yes, get the doctor's order and send to insurance company. If the insurance company says they do not cover this, your choice is to either pay for it out of pocket or let mother go without.
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Reply to Taarna
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Does your mom have Medicare or Medicaid? If a doctor ordered an air mattress it should have been paid by her medical coverage. Fall prevention is another matter and may not be covered due to medical necessity, so you may have to pay for the special bed cushions. Talk to a social worker at the NH.
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Reply to Ricky6
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Check out "foam bed bumpers" on Amazon. They are made for toddlers, but I think some would be long enough for adults. The bumpers are put on the bed like a mattress pad, under the sheet. Sounds similar to what the mattress might do, and be cheaper in the process. If they work, great! If they don't, then you might have to buy the mattress.
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Reply to mavisgm
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Countrymouse Jun 28, 2021
Seriously, don't.

It is the use of equipment and modifications that are not designed for and do not fit the beds they're used on that has led to (rare) fatal accidents and the consequent (almost universal) ban of important, valuable equipment such as bed rails.

Don't skimp and don't bodge. The reason the px'd equipment is so much more expensive is that skill and thought and quality control have gone into it, and these things are not free.
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If the doctor ordered this special type of mattress for your mother then Medicare and her secondary insurance is paying for it.
You say it took six months for them to order an air mattress for her when she first got to the nursing home. So, I'm going to assume that she's on Medicaid. They will pay the entire cost for the mattress.
The nursing home is working a scam on you. They will attempt to collect the cost of the mattress from you and will also submit the bill to insurance. So they get paid twice and none are the wiser.
Nursing homes pull this scam all the time on people. The one my father was in tried pulling it on me. They told me some things for him weren't covered by insurance and would have to be paid out-of-pocket. So before I paid one cent for anything, I checked with Medicare and Medicaid (he was on both by this time). Turns out everything was fully covered. Then the nursing home was discreetly reported to the attorney general of the state he was living in.
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Reply to BurntCaregiver
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the nursing homes should already have these kind of mattresses, as my father had to use one for awhile. And it should come out of the funds that you are paying for his room/board or medicaid. I would discuss with the admin and find out why being charged and let them know you will discuss with your attorney. I bet they will find a way to charge medicaid or they will say it was a mistake. like i said, i would think most nursing homes already have this kind of mattress. wishing you luck
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Reply to wolflover451
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BurntCaregiver Jun 28, 2021
wolflover451,

It isn't considered part of room-and-board costs if it was ordered by her doctor. That is when it becomes medically necessary. Medicare and Medicaid cover medically necessary costs.
The nursing home is trying to work a scam that's been going on for so long in care facilities that it's now a tradition.
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Medicare paid for my Mothers bed and she used it in the nursing home.
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Reply to Isabelsdaughter
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I am not sure where your mother is located, but most DME [equipment) has to have a medical reason unless it is just preferred. Mattresses to prevent bedsores usually is a type that has to first show some skin breakdown and normally orders are written by Wound Care professionals to turn patient or out of bed etc. If patients cannot follow orders, cognitive decline then you are looking at being sure you have the right place for the needs of patient despite the patient might like that nicer place closer to you, problem is the care plan has changed and it sounds like the plan of care includes more than the location is willing to do, so you might be stuck with things. Mattresses are expensive and must have a reason for using them. Falls usually occur with railing down and it really sounds like cognitive decline and patient is being maintained in a facility that does not use railings for this. Need to really understand that most patients might move their care several times before dying . If they have no place to return to then it is best to put them in a place that gradually increase their care in same place vs. Use of a place that they stay for more years then must go to another place when their memory is no longer working. Take out your contract and also recall doctor write orders for everything but it will not be paid by Medicare if not given a medical reason or review so making the job easier for staff, non use of constraints, even soft, rails up, designating falls risk and use of bed alarm to alert, memory testing and if patient safety is get out bed and no one knows this, you are beyond mattress issues.
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Reply to Allye1
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Through her doctor's ordering this mattress, pursue an exemption/waiver from Medicare to pay for the mattress. Or even other insurance she may be covered by, ask for an exemption. The approach would be: "Will the patient get worse without the needed equipment?" I am surprised the DME (durable medical equipment) was not covered by insurance.

Second, remind the nursing home that the funds, (if the NH receives the social security funds or the supplemental security income,) that your Mom has a personal allowance held back from SS, and it may have accumulated if not spent by your Mom. They can take out monthly payments from her personal allowance.

BTW. Where is her Stimulus money, located, or spent for her own needs?
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Reply to Sendhelp
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BurntCaregiver Jun 28, 2021
That's a good point, Sendhelp.

The nursing home by law is not entitled to anyone's Stimulus money. I hope it wasn't handed over to them.
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If they are 'requesting' something special to help your mother from falling out of bed, then you are not 'required' to do anything, nor are they doing something 'illegal' by asking! They are trying to help your mother by getting her a special bed which may prevent her from falling, and the insurance is probably unwilling to pay for it, which is typical of insurance companies in general, so they're asking you to pay for it. If you don't, they can't get the bed for your mother. I think it all boils down to that scenario, personally.

My mother falls out of bed in her Memory Care too. I was asked to get her a new mattress and I wound up getting her an adjustable bed which she hates (but then again, she hates everything in general). It helps the caregivers get her in and out of bed, but it doesn't help her from falling out of the bed. Mats on the floor help cushion the fall. I'm curious to know what kind of mattress this is that prevents these falls? What is the name of it, if you don't mind sharing? I wish my mother's doctor knew of such a thing so I didn't have to waste all the money I wasted buying an adjustable bed she hates when I could've bought something better! Ugh.

Good luck!
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Reply to lealonnie1
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JoAnn29 Jun 24, 2021
My Mom was given a concave mattress to help with her falling out of bed. Just put in concave mattress in my search and it came up all kinds of styles. Prices vary, even Walmart sells them.
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Yes, apparently this special mattress cannot be covered by medicare/medicaid or her supplemental. In that case the home could not absorb the rental cost. These can be very expensive, so get the facts before you do this. We used to have tie on almost like crib borders in hospital and they would be less costly, but also a pain to take up and down to changes and getting people out of bed.
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Reply to AlvaDeer
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sunayana14 Jun 24, 2021
Hi AlvaDeer, thank you so much for the quick response!!
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Yes, it may be over and above what they are required to provide. The air mattress was probably covered by Medicare this one maybe not. If she needed a new wheelchair, Medicare would probably be paying for that, not the facility.

My Moms facility supplied everything but that may be because former residents families donated the item. Moms bed was put as close to the floor as possible with a concave mattress and mats on the floor.

6 months does sound like a long time to place and receive an order. Since you are paying for the item maybe you can find a Durable equipment store that can order the item. Or even on line looking for the best price.
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Reply to JoAnn29
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sunayana14 Jun 24, 2021
Hi JoAnn, thank you, thank you. And for the information about the wheelchair which she also needs. Very helpful!
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