Medicare guidelines for inpatient rehab after a stroke- our new plan is denying Mom's stay.

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Our mother's Medicare Advantage plan is denying her doctor recommended stay in an inpatient rehab facility because it is not "medically necessary."
According to Medicare Guidelines, which the plan is supposed to follow, her stay should be covered if her doctor has certified that she requires:
• intensive physical or occupational rehabilitation (at least three hours per day, five days per week) – Her doctor has certified
• at least one additional type of therapy, such as speech therapy, occupational therapy, or prosthetics/orthotics – Her doctor has certified
• full-time access to a doctor with training in rehabilitation, including at least three visits per week, and – Her doctor has certified
• full-time access to a skilled rehabilitation nurse – Her doctor has certified

Prior to January 1 her Medicare Advantage plan was through a different company and they had covered her first 7 days. Both companies state that they follow Medicare Guidelines. How can one interpret them differently and what constitutes "medically necessary?"

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When we went through this after my mom's stroke first the hospital and then the rehab facility guided us in all of the Medicare/insurance eligibility and prepared us fairly well about what was coming when. As I understand it there are a couple of different levels of "rehab" as well as NHF (nursing home facility) and for actual rehab or maybe it's stroke rehab, in particular Mom at the time acute rehab was key because her speech was so affected and that was the only place to get her the intensive speech therapy she really needed. But he also kept saying we had to get her in one quickly while she still qualified, at the time I thought they were just wanting her out of the hospital bed. As we learned meeting the Medicare parameters is an ever changing, continually reviewed thing and while she met the requirements for "acute" rehab when she went in and the therapists worked at making sure they found a way for her to continue meeting them the time came, quickly it seemed to us, that she no longer met those requirements for "acute" rehab, though she did still meet requirements for Rehab and NHF or a place that's basically a combo where they have rehab patients who are expected to get better enough to come out as well as patients who have made the NHF home. We had decisions and problems because what she really needed was intense speech therapy and a typo of all things in the bill that set the guidelines for rehab therapy makes it so that of the 3 physical, occupational and speech therapies, speech is the only one that cannot stand on it's own to put them and keep them in "acute rehab". But I digress, Acute Rehab is intense and the patients aren't meant to stay there more than 6 weeks I think it is but they get at least 3 hrs a day of each of the 3 (2 of speech, errggg) where as rehab and rehab/nh care provides them whichever they need a couple times a week maybe, speech even less and not from as specialized therapists. Regular rehab is just like getting rehab therapy from home and in fact even though my mom wasn't able to be left alone (we chose to bring her home) we had to choose between Medicare paying for NH, help in the home an hour or two a day or a few days a week or listing her as ambulatory or something like that meaning she can leave the house for therapy and then she could go to outpatient therapy meaning for us she got much better speech therapy. Get some guidance from the person at the rehab unit she is in. It may be that she no longer qualifies for that particular level or rehab unit but does for the next phase down. It may also very well be an insurance thing that you need to fight but again will need the rehabs help. They have not only expertise but a vested interest in helping, they should even know if the denial makes any sense and or how to get around it if that's an option.
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Contact the physician directly - or the billing department.

This is a typical response when the physician uses the wrong code. Have them resubmit.
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I am so sympathetic with your frustration. We just got denied a second appeal for standard Medicare coverage. They covered 20 days only post hospitalization even though he carried supplental Blue Cross as well. He can “walk” 30 feet with contact guard assist, is blind and has Alzheimer’s. He fell for the 5th time, yesterday and is a profuse bleeder. Incredibly enough we are being encouraged to find an AL that can handle him. He’s been turned down by two that say he requires too much assistance. Duh.
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Yes snf is skilled nursing facility.
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I am new to this situation..can you please tell me what snf stand for....,is it senior nursing facility ?
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With my daughters, I always start by finding out who made the choice to deny coverage, and their qualifications. It helps the dr. when they go peer to peer.
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Oh she wasn’t eligible for the snf, oohhhhh thats crazy ...you need a family conference with the therapists and nursing to find out the full story. id ask for a family conference ASAP ....
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I specialize in rehab nursing and I work in a acute care rehab in a hospital..I don’t know about Your managed care insurance,,but the guidelines for acute care rehab is they must be able to tolerate 3 hours a day and she is walking 150feet which is awesome even with the gait belt ...so she wouldn’t qualify for acute care rehab because she can walk 150 feet ,,but she would qualify for a snf unit because of her history of falling ,,that’s the safety issue is her falling ,,which her managed care should place her in a snf unit .,rather than acute care rehab..my rehab wouldn’t accept her because she is walking so far with contact guard holding with the gait belt being held ,,her insurance should have her placed in a snf unit because she falls ,,,now I’m not sure of the guidelines of your insurance or the guidelines of,the snf units in your area ,,150feet is quiet far ...but I would call the insurance company and find out what their plan is ,,does she live alone ? Does she have help 24/7 ..what is her discharge plan ?
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Thank you. We looked into cancelling her Advantage plan before 1/1/18 and getting the Medigap, but since she was in a SNF she was not eligible.
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I will, thanks.
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