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

I had no trouble getting Medicare (Advantage was not available at that time) to pay for a rehab facility after 2 separate knee replacements.
The trouble may be your mothers diagnosis if it requires much attention to medical conditions.

Most rehab facilities are focused on providing PT and OT with the goal of returning the patient to independence or at least self-care. They count on about a 2-3 week stay and have limited diagnostic or treatment capability compared to a general hospital.

Medicare is extremely goal-oriented, where rehab is concerned, and requires quite specific accounting of patient progress. If they felt that they were mostly providing mainly interim nursing care they would quite likely decline coverage.

Have a talk with her physician, explain your problem. Since your Dr. is recommending a "rehab" facility, your best bet might be to see if he will re-write her admitting diagnosis... just a little...not omitting anything, but emphasizing her need to gain strength in some aspects of self care. I'm not assuring you he will be willing or able to do this, or that it will automatically change things, but, coming from the physician it might make all the difference.

Call the insurance company to find out why it was denied. I would say the doctor didn't give them enough justification for the admit to facility. Insurance makes decision on medical need and for rehab - ability to recover to a certain level above where she is now. If she is at your house now, it's very likely (when you find out the reason they denied it) that you will have to take her back to the hospital and get the release to rehab from there. Harder to go to rehab from home.

Doctor could have even discharged her directly to NH and some will admit with pending Medicaid application.

If you filled out the application, look through the list of items they need for verifications (or review what they asked for). Make sure you send every single thing or app likely to get denied. Take the verifications to your local office and ask to speak to a worker to be sure you brought everything they wanted and ask the worker to document that you did provide everything that was needed and you'd like a call when the application is being worked.

As I have stated many times before, in a situation like this DO NOT take the person out of the hospital. Tell them she has nowhere to go and they will get a social worker involved to find a place.
Also, after decades of either no health insurance or lousy, rotten, good for nothing insurance (Kaiser we were forced to pay for because of rip-off Obamacare) when I became eligible for Medicare, I opted for AARP United Healthcare supplement plan G. It does cost me more, but the benefits are great. No co-pays ever, don't need to get referrals, and if I ever needed rehab, it would pay for up to 180 days. If you choose one of these plans at first eligibility, they cannot turn you down and you won't have to be underwritten if you have serious medical problems. I have had months of 2-days a week physical therapy, and did not have to pay for any of it.

herkeeper: As someone else has stated, the best Medicare supplemental plan may, Imho, be plan F.

Yes! My dad had to pay out of
pocket for rehab after a long hospital stay. He truly needed in patient rehabilitation. It was very frustrating.

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.

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 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.

Gettyupgo and others, over the years we have assisted people making Medicare choices. It has been my experience that most hospital and other facilities would rather take straight Medicare and no supplement then deal with advantage plans. They know that Medicare will pay eighty percent of the bill and no hassle and could actually be more then what the advantage plan would pay. Most if not all hospitals have for lack of a better term “charity care” which could be applied to the other twenty percent. If you are low income Medicare has what is known as “extra help” which would mean a very very low figure for your monthly Medicare premiums which are usually taken out of your monthly SS check. All hospitals and most other facilities have a social worker who can help you navigate the system. I would suggest when you are admitted you immediately ask that the social worker drop by your room. If you are low income such as the $800.00 a month mentioned you should be eligible for Medicaid which would cover rehab, drugs, hospital stays etc. you can also have both Medicare and Medicaid.
I would try to line up good coverage before you need it. Try to locate a social worker in your area to help you. If you are a church person speak to your pastor, she/he would probably know someone. If not, ask around, use social media like the neighborhood app or Facebook.
Wishing everyone good health

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.

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.

Medicare contracts out to these Medicare Advantages. They are suppose to follow Medicare A & B criteria.

A while back I print screened this info so I can't copy and paste. But the article says when an Insurance Company turn something down that should be covered u do this:

Ask for the HIPPA Compliance/Privacy Officer

When you get the officer, you ask for the Credentials of every person accessing your records to make the decision of denial.

The article claims that the decision will probably be reversed because they do not want you to know that the person who denied your claim may be a HS graduate with no medical background.

To file a HIPPA violation u contact
US Office of Civil Rights (OCR.gov)

You will need to reach out to her insurance plan and ask them for a list of nearby short-term rehab facilities that take their plan. The hospital she is in need to recommend that she is in need of ST rehab.
I avoid any HMO plans after being advice by a well-known hospital when my dad needed surgery. At that time, I was able to remove my parents from their 'plan' as it was at the end of the year and kept their Medicare separate from their supplement plan. We have since not have any problem with either of my parents' medical care needs when i tell the providers that their insurance coverages are separate including my mom's short-term rehabs. The additional cost saved a lot of headaches and at the end of the day it also saved on cost.
Good luck.

Many times it depends on the insurance provider. In my area there is only one agency that is approved under my plan. Others you have to pay for. It is not the “advantage” plan but the insurance company in the plan you bought. Next year I will be changing my insurance plan/provider to get more providers. Yes it will cost a little more but it will be worth it.

This really isn’t an answer. All I know is that MA plans totally suck. The only thing about them is the extra benefits you get that you can’t get through original Medicare. I’ve found out that when the plans don’t want to pay they throw it back on Medicare guide lines. My husband and has to have a special kind of kneck surgery every 6 months. The MA plan denies it. He called Medicare and they said they cover it. If I could afford it I would pay the extra for the supplemental plan and get rid of my MA. I’m tired of never knowing how much they will pay or if something is covered by just the copay or do you end up with coinsurance.

Sorry to say 'Medicare Advantage' is not Medicare at all, it is a business route to charge Medicare higher fees and many of us now term it 'Medicare Disadvantage', and I joke "Whose 'advantage'?" The promos for 'Medicare Advantage' lure folks in with 'extras' but so often wind up treating people like this OP. Please steer clear of these programs and educate yourselves about the history of how they evolved, how they were allowed to even put the word 'Medicare' into their plan names. If you'd like to know more look into Thom Hartmann's website/column/radio and TV shows: he has been railing about this kind of deceptive practice for years. All the best...try to switch back to regular, REAL, Medicare as soon as you can. Folks over a certain age can do it fairly easily without having to wait for the next enrollment period.

Yes my dad was turned down although he couldn’t even walk. He had fallen down his stairs and laid there for 3 days before being found and was in the hospital 3 week. He was diagnosed with dementia there. The hospital pressed me very heavily to get him into a memory care place for 10k a month. They tried 2 times to get Kaiser to approve rehab but both times they turned it down. Miraculously, toward the end of his hospital stay he regained the ability to walk so I took him home to live with me. The whole experience trying to get him proper care with Kaiser was terrible. I’d never get a Medicare advantage plan with them due to the experience I had with my father.

Never let insurance companies determine what care you receive. Doctors do that.You should immediately file an on line complaint with the insurance commissioner’s office of your state. They make this very easy to do and the insurance companies see it in real time or within a day or two and will be contacting you shortly after that. They take these complaints very seriously and move fast to resolve them. Over the years I have had to do this several times always with a favorable outcome. It is unconscionable that in this situation rehab was denied.

if anybody is reading this and you still have a choice between straight Medicare and a advantage plan please do not listen to Joe Nameith. Straight Medicare and a supplement is the way to go.

Unfortunately, there are not a lot of options. You can do an expedited appeal to try to get the denial overturned. Depending on when the rehab was denied you can do what's called a "Peer to Peer." It's a small window for thst though. The facility where she is going or the facility requesting has to do that within a 24 hour period of notification of the denial of the request. Outside of that calling her insurance and requesting an expedited appeal is the only other thing I can think of. Minus those options anything else would be out of pocket that I can think of.

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.

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.

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)

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.

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.