I can only answer based on my dad's situation. In his case, it is certain that he was kept far longer than he should have been, twice. The supposed rehab was a tiny fraction of each day, so what on earth was he doing there? I will tell you. The hospital (where he also didn't belong, but paramedics refused to leave his house without him) that referred him to skilled nursing/rehab was just named in the local news for taking kickbacks for directing patients into certain substandard facilities. My sister had POA and she is quite naive, so she allowed transfer to a nearby place. He ended up drugged on Nuedexta and forced to stay in bed except for brief daily stints. He entered able to walk, just unstable on a crazy drug regimen. He left an obscene 5 weeks later, needing a walker and with entry-level pressure ulcers on his heels. Criminal.
Then about ten days after he got home he stumbled while his overpaid "caregiver" was outside yapping on the phone. He skinned his scalp on his 5' tall dresser. (I bought dense foam corner shields for it, too late...) When the visiting nurse, whom my parents had just decided to fire, arrived, unannounced, later on and saw the new scrape on his head (after entering his bedroom uninvited) she demanded to know why I hadn't taken him to ER. Because I do not make healthcare decisions for him or my mother, that is why. They were both mentally competent at the time. And because he was fine. He was alert and oriented, his pupils were normal, he reported no pain and no odd feelings, and because he was in good hands and we'd call an ambulance immediately if he appeared to need medical attention. And because last time, a 5-week stay disabled him.
She she called 911, 8 paramedics arrived, and after telling me he had Alzheimer's, which he didn't, they asked him his name, where he was, why they were there, and the date. Because he didn't know the date, they said they had no choice but to take him to ER. Except they didn't take him. They called a private ambulance company that billed $2,000 to drive him 2 miles to the hospital, with no health services provided en route. How much of that goes back to the firehouse is anyone's guess, but I will say it reeked of a racket.
They did something to him in the real hospital that meant keeping him for a week, on Haldol and sometimes in restraints, then shunted him over to a different, worse rehab. My sister, who lives 1200 miles away, oversaw and approved all this while I wept. He was so drugged up when my mother and I visited that he couldn't always be roused. He was there four weeks, and by the end was more wakeful and extremely irritable. Come to find out that two antidepressants and a useless sleeping pill had been added to his drug load. And, he couldn't even walk with a walker. That's when my brother hired two men at tremendous cost, both of whom my dad hated and who hated him, and that was just great because his arm was broken a month and a half later. The man who was paid to stay with him at all times so he couldn't fall wouldn't let him finish a sentence when I asked him what had happened. And then engaged in a tug of war with him over the walker when my dad wanted to get up and leave the room. Twice. We didn't know his arm was broken (and it might not have been), but it was bleeding like mad and my dad had got tired of waiting for the other "caregiver" to simply tape some gauze around it. My dad was so agitated that I couldn't find out what happened, at least not from him. (TWO antidepressants.)
But what really happened is that his legs were all but destroyed on forced, drugged bedrest. My "new" dad's quality of life is about 3 out of 10, down from 8 or 9. He no longer talks for the sake of talking, he usually yells, he watches TV when not asleep, with hours all off-kilter, and he's shadowed by mean men.
I got his doctor to stop the new drugs. I saw his EKG--he had Long QT, a cardiac sign that can lead to death, a known interaction of the antidepressants.
Hospital, NH, etc don't want to be held liable if something bad should happen to mom after discharge and it could get back to the facilities. Many may not know, but these businesses are always looking out for their best interests.
The first 2 appeals are done by non medical insurance employees. The third is reviewed by doctors. Most people give up before then, Keep trying until you finish the 3rd appeal. also, you should not have to pay anything until after the appeal process is finished as she would be listed as " insurance pending" . This doesn't mean you won't be billed if appeal is denied. in the 3rd appeal mention the "Jimmo" medicare case.
My husband is picking his mother up right now from rehab. Her insurance won’t pay any more days, she’s not able to care for herself while we’re at work (she’s lived with us for 8 years) but her condition isn’t bad enough for Medicaid assistance. It is a catch 22 situation. We don’t have the money for in home care while we’re at work so we’re scrambling to find the resources to help. Good luck!
One of the things I learned from our elder law attorney is that they can't make you leave or stay. No matter that they put it in a way that makes it sound like it's up to them, it's up to you. When a hospital tells you it's time to go, it's a request and not a command. It's up to you. When a hospital tells you to stay, it's a suggestion and not a command.
So you can take her home anytime you want to. She's not being held hostage.
By Audie Liametz MD, JD--Relias.com "Simply because a patient elects to leave AMA does not mean that he or she is always entitled to do so. In fact, there are situations in which the practitioner is mandated to override the patient's refusal to stay (i.e., not permit a patient to leave AMA), such as when the patient is: expressing suicidal ideation, lacks decisional capacity, is a danger to others, or poses a public health risk (e.g., active tuberculosis and refusing treatment).
Most patients believe that the insurance company will not pay for their visit if they leave AMA. This is a myth; however, insurance may not pay for a repeat visit for the same symptoms.
It is not too difficult to document the basic elements of an appropriate AMA discharge, including: 1. Decisional capacity; 2. The physician's opinion regarding why the patient should stay; 3. The physician's ongoing concern about the patient leaving; 4. The informed refusal, including possible outcomes and alternatives; 5. Family who are present and aware of the condition; 6. Any other efforts: i.e., family, social work, nursing supervisor involvement, etc. 7. Signatures from the patient and witness(es)." ---------------------------------------------------------------------------------------- This information mostly applies to patients that leave the ER or hospital. In your mom's case, she is stable and not in need of medical treatment to save her life.
In my opinion, I would arrange a meeting with the director of nurses, the physical therapist, the occupational therapist, the doctor, the facilities' ombudsman and the social worker. I would have a list of questions ready. How much longer is her therapy needed? How will this stay be paid for? (especially if you can't pay for it.) What is needed for home modification to make her return possible? Can one caregiver handle her care?
The appointment for the meeting should be made within the next week (to reduce any further costs to you.)
According to what the above information is saying, she would be able to leave Against Medical Advice BUT she may NOT be able to re-enter rehab again with Medicare or other health insurance paying the bill.
Might be a good idea to also talk with an elder attorney. (You can find retired elder attorneys listed in the senior center of your town who work on the ability of the patient to pay.)
You need to get to the bottom of this as the bill keeps increasing day by day.
Dear Et: The steps in your home sound similar to ours. My wife, Alzheimer’s , fell and broke her femur. Plateaued quickly and we had to bring her home. Bought a light weight transfer wheel chair, and bought a 6” aluminum ramp to negotiate the steps. Problem solved. Once at either level we went back to her waloking and using her legs, getting her balance, etc. Within (6) months we were able to negotiate the two steps with just one person holding her hand. NOTE that one person must always be ahead of and somewhat in front of the patient, looking at them, one hand under her arm and one holding the lead hand. We no longer use ramps or transfer chairs but she will always need assistance.
They are just trying to keep her money. Contrary to what they say, she can check herself out at any time, as long as she”accepts the consequences”. If you pick her up and take over, they can’t refuse.
You can take her home " against medical advise" But it will mess seriously with your insurance. Can you get a lift , ramp or rails in the house . Get in home PT for her to help her with the steps and standing . Get a bed handle (fits under mattress) to help her stand if she feels the need for something to steady her. I think id see an Attorney too ,one that specialize in hospital , medical issues if you can find one.
Let me answer from the patient's perspective which I rarely see on this site. Do remember that these facilities are often for profit and even if not for profit they still want to keep their beds filled. So they will try to force a longer stay if they think you can pay for it. I have been in this situation --they said that I was not going willingly and was "self-limiting" at physical therapy. Well I had contracted recurring CDIFF there and it was rampant in that place and in so many others. I was very sick and getting sicker. That is the dirty secret of rehab--you often get sicker there because of infections and staff not following their own posted protocols. So I announced that I was leaving and went home in an ambulance. Do not let them bully you.
You do not NEED their approval as all those in the medical field give advise and are not gods. Too many times these so called professionals overstep their bounds and assume they are the definitive authority. YOU are the one who chooses the best course of action to take and if that means bring her home then bring her home! I am talking from a legal aspect which seems to be ignored here. TELL THEM SHE IS COMING HOME and then bring her home.
If there are only a few steps up into the house please check out "Raase Lift". Wheelchair lifts can be expensive but this powered wheelchair ramp isn't much more expensive than a winding wooden ramp in front of the house (which some subdivisions won't allow). The best thing is that the ramp is only 8 feet long and can usually be installed inside an enclosed garage (away from rain/snow/ice).
You know you can take her home = Against Medical Advice. They will probably ask you to sign papers == which is reasonable. But they can't keep your mom if she wants to leave or the person who has medical guardianship wants her to leave. The fact is you can just walk her out as long as she wants to go and/or you have proper authority.
Quite, Shad - unless you are very confident that your mother will never need to see a doctor again, given the importance of the insurance cover, it's a bad idea to discharge against medical advice.
So the issue is literally these four steps in the home? That's the lot? Then you have two options:
pay for the continued rehab and encourage your mother to work it! work it! on those steps (which would be good for her strength, balance and confidence) - in which case, too, instead of arguing with rehab you want to argue with Medicare;
or
get quotations for a ramp, stair lift or double hand rail for those stairs; and/or ask the OT what adaptations would satisfy their discharge criteria.
But if Medicare have you chipping in in the background about how you're sure mother would be fine at home now then it's hardly surprising they've turned down the extended rehab, is it? Personally, I'd go for the "argue the claim and cheerlead the PT" option.
Many facilities (and doctors) use the against medical advice spiel in these instances and/or the threat to report to Medicare so if something bad may happen do to AMA Medicare may not pay.
I am not trying to overstep my bounds but when I was told my mother could not leave the nursing home in order to go home with me my mother went as they put it AMA. That stands for against medical advice. She can get treatment at home and the rehab facility cannot stop her from leaving. She still has rights in America.
They either want to get as much money from her as they can and/or set her up with after rehab services selected by them. The doctor would want to be involved as well because every home visit could be billed to Medicare.
Do you have two people on hand who can consistently get her up those steps?
Have you spoke directly to the supplemental insurance co to ascertain that they received all of the documentation?
Is she walking consistently within the facility, not necessarily in the therapy room? Just with an aide, say with a gait belt? Or is she resistant to getting out of bed?
Has she had a stroke? Are there underlying mental health issues?
Just trying to get a fuller picture.
You can call the ombudsman if you truly feel that she's ready for dishcarge and they are not letting her go unfairly. You can appeal the appeal to your state insurance commission, I think.
Thank you Barb....the rehab team....social worker, therapists , admissions all worked together to appeal the insurance decision. They said they faxed 60 copies over. I had to call also to explain her condition, as they told me what to say to the appeals board. I feel like she is capable of coming home with my continued care, but the therapy room scares her, and she fears standing up. She walked 80 feet though once she did! I told them I have a good setup at home in place...everything she needs, but 4 steps up into the main living area of house is what they are concerned with! Two people can surely get her up those steps! I just feel they are trying to keep her longer for the money. ???
When you appealed, did you do so with the support of the therapy and medical staff? Did they document that she was still making progress? If THEY think she's plateaued, neither Medcare nor her supplement will pay for continuted therapy. She then needs to become a long term care patient.
Ask the head of the therapy department to go over with you what they've submitted. Appeal again if they are saying she's still making progress.
Ask rehab what they need in place at home for discharge. They need to send an OT out to evaluate her home.
Yes...mom was hospitalized...now in day 23 of rehab. I thought her Medicare supplement would cover her for day 21-100, and we would pay a copay for her continued care, since the dr. says she cannot come home yet. I am her full-time caregiver in her house. Her Medicare supplement insurance is saying now, after we appealed once, that she can now be under custodial care. But rehab won't discharge her! I am trying to stay clear of Medicaid if I can, but now we have to pay full price, and that will take all of savings within a very short time!😢
Et, being held hostage means that they are demanding money for her release. That isn't what's happening, is it.?
Deep breath. I'm going to guess that mom is in rehab after a hospitalization. The therapists are saying that she's made all the progress that she's going to, and thus Medicare will no longer pay for rehab.
But she's not safe to go home, according to the doctors. Meaning that she needs a higher level of care than living alone. She may need a long term care facility, or she may need in home care.
It's time to figure out what mom's resources are AND to talk to the discharge planners about what her level of need is.
If she has no resources for long term care, you appt for Medicaid.
Etowahrivergirl, can you tell us why your Mom is in a rehab facility? If she has been there for 20-21 days and has not improved, then it is up to her health insurance as to whether they will pay for extra days.
If Mom is improving, then her insurance should allow her to stay more days, but Medicare would only pay for part of those days, and hopefully Mom's secondary insurance will pick up the rest.
Sounds like miscommunication between the rehab facility and Mom's health insurance.
Then about ten days after he got home he stumbled while his overpaid "caregiver" was outside yapping on the phone. He skinned his scalp on his 5' tall dresser. (I bought dense foam corner shields for it, too late...) When the visiting nurse, whom my parents had just decided to fire, arrived, unannounced, later on and saw the new scrape on his head (after entering his bedroom uninvited) she demanded to know why I hadn't taken him to ER. Because I do not make healthcare decisions for him or my mother, that is why. They were both mentally competent at the time. And because he was fine. He was alert and oriented, his pupils were normal, he reported no pain and no odd feelings, and because he was in good hands and we'd call an ambulance immediately if he appeared to need medical attention. And because last time, a 5-week stay disabled him.
She she called 911, 8 paramedics arrived, and after telling me he had Alzheimer's, which he didn't, they asked him his name, where he was, why they were there, and the date. Because he didn't know the date, they said they had no choice but to take him to ER. Except they didn't take him. They called a private ambulance company that billed $2,000 to drive him 2 miles to the hospital, with no health services provided en route. How much of that goes back to the firehouse is anyone's guess, but I will say it reeked of a racket.
They did something to him in the real hospital that meant keeping him for a week, on Haldol and sometimes in restraints, then shunted him over to a different, worse rehab. My sister, who lives 1200 miles away, oversaw and approved all this while I wept. He was so drugged up when my mother and I visited that he couldn't always be roused. He was there four weeks, and by the end was more wakeful and extremely irritable. Come to find out that two antidepressants and a useless sleeping pill had been added to his drug load. And, he couldn't even walk with a walker. That's when my brother hired two men at tremendous cost, both of whom my dad hated and who hated him, and that was just great because his arm was broken a month and a half later. The man who was paid to stay with him at all times so he couldn't fall wouldn't let him finish a sentence when I asked him what had happened. And then engaged in a tug of war with him over the walker when my dad wanted to get up and leave the room. Twice. We didn't know his arm was broken (and it might not have been), but it was bleeding like mad and my dad had got tired of waiting for the other "caregiver" to simply tape some gauze around it. My dad was so agitated that I couldn't find out what happened, at least not from him. (TWO antidepressants.)
But what really happened is that his legs were all but destroyed on forced, drugged bedrest. My "new" dad's quality of life is about 3 out of 10, down from 8 or 9. He no longer talks for the sake of talking, he usually yells, he watches TV when not asleep, with hours all off-kilter, and he's shadowed by mean men.
I got his doctor to stop the new drugs. I saw his EKG--he had Long QT, a cardiac sign that can lead to death, a known interaction of the antidepressants.
So you can take her home anytime you want to. She's not being held hostage.
"Simply because a patient elects to leave AMA does not mean that he or she is always entitled to do so. In fact, there are situations in which the practitioner is mandated to override the patient's refusal to stay (i.e., not permit a patient to leave AMA), such as when the patient is: expressing suicidal ideation, lacks decisional capacity, is a danger to others, or poses a public health risk (e.g., active tuberculosis and refusing treatment).
Most patients believe that the insurance company will not pay for their visit if they leave AMA. This is a myth; however, insurance may not pay for a repeat visit for the same symptoms.
It is not too difficult to document the basic elements of an appropriate AMA discharge, including:
1. Decisional capacity;
2. The physician's opinion regarding why the patient should stay;
3. The physician's ongoing concern about the patient leaving;
4. The informed refusal, including possible outcomes and alternatives;
5. Family who are present and aware of the condition;
6. Any other efforts: i.e., family, social work, nursing supervisor involvement, etc.
7. Signatures from the patient and witness(es)."
----------------------------------------------------------------------------------------
This information mostly applies to patients that leave the ER or hospital.
In your mom's case, she is stable and not in need of medical treatment to save her life.
In my opinion, I would arrange a meeting with the director of nurses, the physical therapist, the occupational therapist, the doctor, the facilities' ombudsman and the social worker. I would have a list of questions ready.
How much longer is her therapy needed?
How will this stay be paid for? (especially if you can't pay for it.)
What is needed for home modification to make her return possible?
Can one caregiver handle her care?
The appointment for the meeting should be made within the next week (to reduce any further costs to you.)
According to what the above information is saying, she would be able to leave Against Medical Advice BUT she may NOT be able to re-enter rehab again with Medicare or other health insurance paying the bill.
Might be a good idea to also talk with an elder attorney. (You can find retired elder attorneys listed in the senior center of your town who work on the ability of the patient to pay.)
You need to get to the bottom of this as the bill keeps increasing day by day.
Good luck.
The steps in your home sound similar to ours. My wife, Alzheimer’s , fell and broke her femur. Plateaued quickly and we had to bring her home. Bought a light weight transfer wheel chair, and bought a 6” aluminum ramp to negotiate the steps. Problem solved. Once at either level we went back to her waloking and using her legs, getting her balance, etc. Within (6) months we were able to negotiate the two steps with just one person holding her hand. NOTE that one person must always be ahead of and somewhat in front of the patient, looking at them, one hand under her arm and one holding the lead hand. We no longer use ramps or transfer chairs but she will always need assistance.
Do remember that these facilities are often for profit and even if not for profit they still want to keep their beds filled. So they will try to force a longer stay if they think you can pay for it. I have been in this situation --they said that I was not going willingly and was "self-limiting" at physical therapy. Well I had contracted recurring CDIFF there and it was rampant in that place and in so many others. I was very sick and getting sicker.
That is the dirty secret of rehab--you often get sicker there because of infections and staff not following their own posted protocols. So I announced that I was leaving and went home in an ambulance. Do not let them bully you.
So the issue is literally these four steps in the home? That's the lot? Then you have two options:
pay for the continued rehab and encourage your mother to work it! work it! on those steps (which would be good for her strength, balance and confidence) - in which case, too, instead of arguing with rehab you want to argue with Medicare;
or
get quotations for a ramp, stair lift or double hand rail for those stairs; and/or ask the OT what adaptations would satisfy their discharge criteria.
But if Medicare have you chipping in in the background about how you're sure mother would be fine at home now then it's hardly surprising they've turned down the extended rehab, is it? Personally, I'd go for the "argue the claim and cheerlead the PT" option.
Many facilities (and doctors) use the against medical advice spiel in these instances and/or the threat to report to Medicare so if something bad may happen do to AMA Medicare may not pay.
Have you spoke directly to the supplemental insurance co to ascertain that they received all of the documentation?
Is she walking consistently within the facility, not necessarily in the therapy room? Just with an aide, say with a gait belt? Or is she resistant to getting out of bed?
Has she had a stroke? Are there underlying mental health issues?
Just trying to get a fuller picture.
You can call the ombudsman if you truly feel that she's ready for dishcarge and they are not letting her go unfairly. You can appeal the appeal to your state insurance commission, I think.
When you appealed, did you do so with the support of the therapy and medical staff? Did they document that she was still making progress? If THEY think she's plateaued, neither Medcare nor her supplement will pay for continuted therapy. She then needs to become a long term care patient.
Ask the head of the therapy department to go over with you what they've submitted. Appeal again if they are saying she's still making progress.
Ask rehab what they need in place at home for discharge. They need to send an OT out to evaluate her home.
Deep breath. I'm going to guess that mom is in rehab after a hospitalization. The therapists are saying that she's made all the progress that she's going to, and thus Medicare will no longer pay for rehab.
But she's not safe to go home, according to the doctors. Meaning that she needs a higher level of care than living alone. She may need a long term care facility, or she may need in home care.
It's time to figure out what mom's resources are AND to talk to the discharge planners about what her level of need is.
If she has no resources for long term care, you appt for Medicaid.
If Mom is improving, then her insurance should allow her to stay more days, but Medicare would only pay for part of those days, and hopefully Mom's secondary insurance will pick up the rest.
Sounds like miscommunication between the rehab facility and Mom's health insurance.