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My mom is 90 and fell and broker her arm and has been in a Skilled Nursing Facility for about 35 days. Before she fell she was driving fine and is very extremely cognitively "with it" and has lived alone pretty much doing fine although she tires very easily. For the past week to 10 days in the nursing home she has been walking independently with no walker or cane. When the PT and OT evaluate her she is able to do everything with absolutely no assistance. She can go to the bathroom by herself, make a meal in the microwave by herself, dress and undress by herself, do a full set of stairs up and down by herself (holding onto the hand rail). She is slow and careful, but she's been through two evaluations and each time they say she is just a little tentative and therefore they won't clear her to go home.


The problem lies in that at day 31 of her stay, her secondary insurance stopped paying and now she is paying $167 per day co pay. She has a very low income and can't afford this and wants to go home. She has had fantastic PT and OT seven days a week and is actually in better shape than before she fell... but they won't clear her, so she has decided that she is leaving Against Medical Advice to go home. Her primary doctor who knows her quite well has already agreed to coordinate home PT and OT and other social services she might need... she does get tired very easily due to congestive heart failure so she receives Meals on Wheels etc.


My question is... should I be worried about her leaving Against Medical Advice? Someone at the nursing facility mentioned calling Adult Protective Services if she leaves and while my main concern is for my mom, I am also worried if I'll be responsible if she goes home and something does happen... if she falls. Also, I heard that her secondary insurance might not pay if she leaves AMA.


Unfortunately, I live a couple of hours away. I told her tonight that I think she should stay until they clear her, but it seems that she has to be absolutely perfect in the evaluations for her to be cleared. I understand that they don't want to be sued, but it seems ridiculous. She is is in so much better shape than any other patient in that facility by miles. Everyone there is walking with a walker or they are in a wheel chair or bed except my mom. She doesn't even look like she belongs there. Even the PT and OT techs are whispering to her that she should be discharged and they don't understand why they won't clear her.


Is this Medicare fraud... trying to keep her there so they can bill for her stay? Why else would they not clear her?


Any advice is appreciated.

I told them when Mom went in just to get her strength back, that she was only staying the 20 days Medicare paid fully because there was no money for the $150 days after that. She was discharged in 18 days.

Go to the finance office and tell them Mom has no money for the extra days. That they need to discharge her or agree not to be paid. Bet she is discharged. Mom can do therapy at home, I think. Check that out with insurance provider. If they do nothing, call her primary. If get nowhere with that, call your state Ombudsman.
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Reply to JoAnn29
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I really hate Rehab facilities; they can sometimes CREATE more problems than they cure. When my dad fell & broke his hip in 2014, he wasn't making 'proper' progress in Rehab so they insisted on putting him in their skilled nursing section which was a DUMP and something we couldn't do. His PT did everything in his power to PREVENT me from getting him *and my mom* into an Assisted Living Facility!!!! He promised to tell the ALF that dad was in NO shape to live there and that he belonged in Skilled Nursing! He threatened me on a daily basis and my anxiety level was thru the roof as a result. I finally told him OFF, suggested he speak only the truth to the ALF when they called and to leave his personal feelings & opinions OUT of the conversation. Dad wound up getting into the ALF, thank God, in spite of the miserable PT and his interference.

I love Joann's suggestion to tell the facility you have NO money to pay for further services. I'll betcha too that they release your mom pronto.

Best of luck!!!
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Reply to lealonnie1
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Well----Medicare is the highest reimbursement rate for skilled nursing care. So, facilities tend to want to keep residents using Medicare payment as long as possible. They even try "hard ball" tactics with threatening to call Adult Protective Services. The potential problem with leaving Against Medical Advice (AMA) is that the doctor she has at the nursing home won't order any services or prescribe needed medications for the person when they leave. However, your mom's primary doctor, in the community, is willing to do such. If you feel comfortable with your mom leaving, your mom's doctor is ok with it and your mom wants to leave, there shouldn't be a problem. Your mom can receive some more therapy while she is at at home and home bound.

If you are afraid Medicare will not pay for her nursing home bill if she leaves AMA, I have previously researched this with Centers for Medicare and Medicaid Services (CMS) and that is not true. It is another falsehood nursing homes tell families and residents.

Your mom may fall at home. She may fall in the nursing home. But, she will likely get stronger at home with therapy where she has to do more for herself---but more importantly she will be happier at home.
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Reply to Ombudsman1
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I have been thinking about this. If the telling them there is no money doesn't work call Medicare. Explain that Mom has no money for further PT. You have been told she is progressing well and she would like to leave. Medicare tells them whether Mom can stay based on the reports sent to them from therapy. They will review her progress and they can tell rehab to release her to PT at home. Once Medicare won't pay and you can't pay, she will be realeased. She may do better at home.

I was told my Mom, even with a walker, would need assistance at all times when she returned to the AL. I questioned it because she was only in the hospital, for a UTI, from Tues to Friday. Before that she was walking all over the AL with a walker. When she returned to the AL within 24 hrs she was again walking all over the place.

I really don't see how they can get better when they do PT, OT for maybe a couple of hours a day and then sit them in a wheelchair the rest of the time.
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Reply to JoAnn29
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Heres how I did it. After a week in a rehab care facility I was not impressed with the care. My mom was dressing, feeding, and making it back and forth to the bathroom without assistance. I told them that we had decided that we had enough help to care for her at home. That her personal physician had ordered visiting nurse and PT and that I was flying in a relative that was going to live with her for a few weeks. I also had a vacation week coming and I would take a week with her. I insisted on being part of the evaluation meeting and sat with the people who made this decision. They were not happy but they did what I asked. It is not AMA if you have the care in place at home for your mom. You can decide that you don't want to use a rehab and bring her home instead. $160 dollars a day can pay for in home care at least part of the day. But you have to be there to let them know that you have organized all this. They can't really say no.....
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Reply to Meisie1
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My mom is 83 and lives in an assisted living facility. When she falls, they generally send her by ambulance to the hospital. On one occasion, however, they did not do this; instead, they called my sister and she took her to Urgent Care to have her checked out. Urgent Care's CAT scan was down and, since she said she had hit her head when she fell (no one saw her fall), we wanted to make sure there was no fracture or bleeding on the brain. My sister then took her to the ER. At the ER, they kept her for about 8 hours. Finally, they did the CAT scan, which was normal. My sister asked that they do a urine culture because Mom has frequent UTIs and was acting confused. That's when they decided to admit her. We thought it would be just an overnight thing. We were wrong. Every day my sister or I would call the hospital to ask when she would be released. We also asked for a diagnosis. We got nothing. The attending doctor would not meet us face to face but called our cell phones while we were at the hospital to speak to us! No one could tell us why she was still being held. They did nothing for her but tell her to stay in bed all week and give her the meds she had been taking all along. She felt fine and told them so often. Finally, I had a showdown with the nursing supervisor. I said "tell me what her diagnosis is and WHY she is still here." The nurse hemmed and hawed. I asked to speak to the doctor and - once again - he called on my cell phone. He was all wishy washy about why she was there. I was ready to take her out AMA, but was told she could not return to her assisted living facility if we did that. Then, I said I was getting a lawyer. That was the magic phrase. In less than 10 minutes, a physical therapy specialist was coming down to evaluate her to see if she could walk. Well, Mom got out of bed and fairly raced down the hall way. The PT specialist said "there's no reason she can't go back to her facility - why is she still here?" We were out of there 30 minutes later. Found out afterward that elderly patients on Medicare are kept a certain number of days so that the hospital can collect payment. There had never been a physical reason for her to be admitted or kept there for a week. This was a state teaching hospital too. Mom has never gone back there - she is afraid if she does, she'll never be allowed to leave.
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Reply to lablover64
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You state that "at day 31 of her stay, her secondary insurance stopped paying and now she is paying $167 per day co pay." Why did the Secondary Insurance stop paying? Isn't it a Medicare Supplemental Insurance that pays for what Medicare does not pay for? 

My 87 year old Mom did NOT have to pay for anything when she was in Skilled Rehab because her BCBS Medicare Supplemental Insurance covered what was not paid by Medicare. 

You and your Mom need to contact the Secondary Insurance Company and find out WHY they quit paying for her care and why she is having to pay a Co-Pay?  What part of her care did the insurance company quit paying for?  Sometimes nursing homes make mistakes on the forms that they have to send to Medicare and to the Medicare Supplemental Insurances which can result in nonpayment or a lower payment from Medicare or the insurance company.

Also, have a meeting with the people who make the decision as to whether your Mom can go home or not.  Ask for the specific reason(s) why your Mom cannot go home.  What do they mean when they say that “she has to be absolutely perfect in the evaluations for her to be cleared”?  Is it something as simple as the need for a permanent grab bar in the tub or shower? Does she need rails on the toilet? Do the dishes in the kitchen cupboard need to be rearranged so that she can reach them easier? Is the microwave TOO high for her to use safely?  Does she need better handrails on the steps into her house or inside her house? Do the people who make the decision think that there are TOO many steps into your Mom’s house and are afraid that she might fall trying to walk up or down the outside steps?  Are there area rugs that need to be removed so that your Mom does not trip over them?  Does your Mom have an “Alert button” in her house that she can push in case she falls again or does not feel well?  Find out what is keeping “THEM” from releasing your Mom to LIVE BY HERSELF again.

WHO at the nursing facility mentioned calling Adult Protective Services if your Mom leaves AMA?  Did they give a reason why they might call APS other than “your Mom left the nursing home and you took her to her home AMA”? What are their concerns? 

You need to ask more questions and find out exactly WHY "THEY" will not let your Mom go home.  It might be because she is 90 years old and you live 2 hours away.  You won't know unless you ask them.  Good Luck.
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Reply to DeeAnna
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JoAnn29 Dec 23, 2018
Depends on how much you pay for supplimental on what they cover. More money better services.
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Call her insurance and find out if she leaves AMA will they cover!! Don't leave an important decision to hearsay, innuendo, and gossip. I wondered about this and called both my insurance companies and my husband's insurance companies. Turns out, they will pay if he had been admitted.

I did this because several years ago the hospital was going to put my husband in a skilled nursing facility to teach him to walk. To make a long story short, he had been walking fine when they admitted him for a heart problem. They had kept this 83 year man in one position for a week. No turning, no moving around. The last day they had a Physical Therapist get him up and he had a hard time walking. I told them it wasn't going to happen. All he needed was to get up. They were getting the AMA paperwork ready when (Wow) the regular release papers showed up. In an hour he was walking just fine. All he needed was to move around a little bit. Of course I am leaving out my "talks" with the Doctor and a lot of other garbage.
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Reply to MaryKathleen
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Isthisrealyreal Dec 28, 2018
Great job. It is horrifying how little medical staff knows and the things they put people through because of it. Your husband is one blessed man. Hugs!
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I'm thinking the facility does not want to discharge your mother because she is the best patient they have. Feeds herself, dresses herself, walks, etc. They like the fact that she doesn't need nursing care. Also....every facility has a bulletin board somewhere with info on how to reach an omsbudsman. Check this out.
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Reply to GranJan
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Sounds like the advice to actually talk to Medicare and the secondary insurance carrier to state your situation and see what they say.  Gossip and rumors can cause a lot of trouble and the thing is, insurance is complicated, so what one person experienced in their case, may not be the same for you in your particular circumstances.  It is one thing to refuse to pay the bill so far, and another to state that if you leave AMA, they will not cover if you have to go right back.  So actually talking to Medicare and secondary insurer should help to make things clear in your particular situation.
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Reply to rovana
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