Anyone have any experience with insurance (Medicare Advantage Plan) declining recommended short-term rehab after a hospital stay?

Hi, I recently went through something similar with my father after he had a stroke. His Medicare Advantage Plan did agree that he should go to rehab, but after only three weeks they denied his coverage. There is a process for appealing denials. The social worker or case worker at the hospital should inform you of the process. I don’t understand how they can deny discharge to rehab if this is what the doctor and therapists are recommending.

In my father’s case, the process involved me getting access to all his therapy reports from the rehab facility, getting the “detailed explanation of Medicare denial” that specifically states their reasoning for denying coverage, and then calling a phone number supplied on the denial form to initiate the appeal. You have until noon of the following day after receiving the denial form to make the phone call. It’s important to have prepared a statement as to why you feel the denial is wrong. Make sure you focus on the doctors’ and therapists’ recommendations for rehab and that she needs a higher level of care than can be provided at home and that it would be unsafe for her to discharge home without rehabilitation (given specific examples of things she cannot do without rehab to get stronger). A decision is made within 3 days. If the decision goes against you, you can file another appeal. I did get to this point in my father’s case because I did not have enough time to get all the necessary documentation. In his case, his Medicare insurance company claimed he was not making progress and declining. Because I had the therapists’ notes, I could directly refute each of their claims with specific data and examples showing that he was making significant progress. Took 14 days to get the decision but it did go in our favor so they had to cover his two months of inpatient rehab therapy (less the copay you are responsible for after 20 days. Fortunately for my family, I am a Speech Therapist so I have a medical background and knew how to read the reports to support our position. Also, keep in mind that the hospital cannot discharge your mother if she is not safe to return home. Get the case worker involved and if needed, find out who your county ombudsman is in your state. Their job is to help mediate between the insurance company and you and your mom. I found them to be very helpful.

Follow-up to my previous post. One of my colleagues put together this information as these denials seem to be common practice by Medicare Advantage (MA) plans.

The patient/caregiver/family can file a complaint with Medicare through 1-800-Medicare or the Medicare ombudsman: https://www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-Beneficiary-Ombudsman-Home

If it is a denial from the MA plan directly, then you need to review the remittance advice to determine why it was denied. MA plans are allowed to put additional restrictions on coverage using proprietary utilization management. Read the fine print of your policy to determine if certain diagnoses or conditions are exempt from coverage.

MA prior authorization has been getting a lot of scrutiny based on an Office of Inspector General Report released in April: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp.

There was recently an article in The NY Times about this report. https://www.google.com/amp/s/www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.amp.html

The report highlighted the use of prior authorization denials that violate the MA plan's own coverage policies and the high rate of appeals success in which the MA plan ultimately overturns its own denial. Appeals timelines can be lengthy and its frustrating to see patients suffer while they wait. But that is the only way to ultimately gain access to care. The prior authorization problem is so bad, Congress is working on bipartisan legislation to reign it in: https://www.congress.gov/bill/117th-congress/house-bill/3173?s=1&r=5.

Even the trade organization representing MA plans realizes the writing is on the wall and they have endorsed this bill: https://www.congress.gov/bill/117th-congress/house-bill/3173?s=1&r=5.

So, in summary:
1. Find out who is denying access to the services- the rehab or home health agency or the MA plan (or both).
2. If its the rehab or agency, complain to Medicare and show them these resources refuting misinterpretation of the payment system.
3. If it's the MA plan appeal, appeal, appeal, appeal!
4. Always get the physician who ordered rehab or home care involved.
5. Contact your members of Congress and encourage them to support H.R. 3173.

Medicare advantage is one of the biggest scams being pushed on the American people today. Sure it sounds great, with more money in your pocket every month and other claimed "free " stuff, and if you remain healthy and have a good network of DR's participating in the MA plan, it seems pretty good. But god forbid, once you get sick and really need coverage, you very well may be out of luck. All of that money back into your pocket every month comes from somewhere and a good chunk is denying claims and service when you really need it.

I saw in the current issue of AARP an article about medicare advantage programs denial of coverage and how it is now being addressed as a real problem. It's in the June AARP Bulletin and is on page 4, title "Care Wrongly Denied" (Fed Report Targets Medicare Advantage Plans)

Hopefully one of the aggressive class action law firms will file a class action suit again the Medicare Advantage plans, obviously including their executives.  Hopefully one of the tv newscast programs will provide support and publicize this despicable treatment of people in need.

In the meantime, as already suggested, file a challenge to the decision.

Another reason I don't have a MA. I cringe every time a commercial comes up. At least now they have to say its a MA plan not that we are not getting out full Medicare benefits.

MAs are to allow what Medicare would under A & B. As I have stated before, my daughter was an office unit manager that fought with them all the time.

Declining rehab coverage is one of the many drawbacks to having a Medicare Advantage Plan. People buy them b/c they are cheaper than other options, but then end up in situations like yours. You will probably have to pay out-of-pocket for rehab or respite care.

When renewal time comes around, consider returning to regular Medicare and buying Supplemental insurance. It will cost more than an Advantage Plan, but it may serve you better when you need services covered.

When mom had to go to rehab with Medicare Advantage or one of those crappy plans, here's what I found out. There's only SO MANY beds available for THAT PLAN in the rehab SNF. Say 3, for example. Once those beds are occupied, you'll be TURNED DOWN for rehab at that facility. So you need to move onto another facility to see if there's 'room' for your Medicare plan. Get the social worker involved to make phone calls to find her A BED AVAILABLE for her Medicare plan in a rehab SNF. I hope that makes sense.

DONT TAKE HER OUT OF THE HOSPITAL NO-MATTER WHAT THEY TELL U,SHE WILL LOSE HER RIGHTS TO GO TO REHAB IF SHE IS SENT HOME,,DONT AGREE TO TAKE HER HOME,U CANNOT AND ARE NOT RESPONSIBLE FOR HER

When we first took medicare our insurance advisor explained to take the best supplement available even though it was more costly. In our case I believe it was plan F. They explained once you go down a level or take an advantage plan you can not go back up. That may no longer be the case, but we have continued to pay the $300+ premium every month for the highest level even though so far we have not used all the benefits. There are insurance agents licensed to explain all of the plans etc with NO charge to you. They will also investigate the Medication part D options based on what meds you are prescribed. I contact my agent every fall to be certain our insurance provider is the best choice. I have changed companies 3 times in the 10 years I have been on medicare.