She had just a couple of sessions I believe. Now, afterward, they want her to sign the consent, the HIPAA, and financial responsibility because it should have been done before treatment. I have seen no records for this.

Normally I think a provider would apply for the insurance no later than the first session to verify it is covered. I am not comfortable signing her up now (As POA the wording on the forms is inappropriate for me to sign). There is even a form agreeing to phone calls to your cell phone, I assume for marketing.

My state is NC. While I do not have a problem with insurance/Medicare covering a couple of sessions, I do not know how many sessions there were. If insurance does not cover them retroactively, she would have to pay for something she does not want. Mother was verbally guaranteed it would not cost before I was involved.

What is the best course from a legal standpoint? I really don't want to cloud my dealings simply with what I think is right or just, but what is the best course for everyone from a legal viewpoint. Again, I am in NC.


My Mom had some therapy at the AL. They had to have a doctor's order to bill Medicare and Moms supplimental. They had a group they worked with that came to the AL. This just sounds strange to me.
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Reply to JoAnn29
enderby Aug 23, 2018
This is a group who works at the IL/AL. What is strange is the way the PT went about this. He acted more like a timeshare salesman than a health professional.
In this state they did away with most state based providers a few years ago in favor of using all private providers. That created a feeding frenzy of private providers selling all sorts of services, and many providers were started just to cash in on the change. This could be one of the results.
I think a licensed therapist can establish a need for service, but there are still Medicare requirements for payment such as a signed consent to treat form and a treatment plan.
These are helpful answers that give me great ideas to work with. Difficult as I was not aware of this therapy until after it had been started.
The IL has onsite PT, but when my other elders needed care in their IL and AL in this area the providers were not employees. They were just provided an area to work.

To address some of the important points mentioned in your posts:
The PT was not really necessary, but more of a exercise/mobility treatment.
She was approached and sold the therapy on the basis of no risk/no charge.
The therapy group did not do the proper paperwork.
They tried to get me to sign as POA, but the forms specified total financial responsibility, acceptance of robocalls, and full HIPAA release.

I have a much better focus from your answers. I believe they would not try to hold her financially responsible, as I have also read that non-emergency treatment without a prior signed consent form can actually be considered assault. Good to know about the noncompliance, but in this case the need was determined by the therapist, and I am quite sure they did not check with Medicare/insurance. Pretty easy to establish need with her doctor if it becomes urgent in the future.

I love the idea of asking the therapy group to create a new document stating they may bill the insurers but that she will not be responsible for any unpaid portion. That would allow them to attempt billing and not hold her responsible for their mistake.

Thanks for the great insights. I don't know what I would have done the last four years without the good people here.
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Reply to enderby

There is often language on these forms stating the patient agrees to pay any balance due after insurance has been processed. Could they write up something similar that states the facility accepts the determination of insurance reimbursement as payment in full? I agree that somebody dropped the ball but if insurance doesn't reimburse them, they may bill your mother directly.

Was the therapy ordered by a doctor or did your mother just accept services that were offered to her? I think if it was presented to your mom as "try out these PT services, risk free" then they are just out of luck.

And I've toured two independent living facilities that had onsite medical services like PT, hearing clinics and podiatry. It's not unusual in my area.
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Reply to Marcia7321

I see where Igloo is coming from but not sure if what she is saying is what your asking.

I agree with you. I would think the Therapy group would get their ducks in a row before they started any kind of therapy. Evaluate her for the service. Make sure they will get paid by running their findings by Medicare and her suppliment. Somebody at their end dropped the ball. No service is given until that paperwork is signed. Its now in their court. Who recommended that Mom have the therapy? Does Mom have Dementia? Did you know anything about this? I would need a lot more info to take on the responsibility of signing. Is this therapy group able to bill Medicare and the supplimental. If they r able to bill Medicare than call Medicare and see if they got approval for Mom. Same with the supplimental. If not, they don't have a leg to stand on. If so, tell both Medicare and the supplimental ur story and see what they say. My opinion, if its found they jumped the gun, then all you owe is the balance left after what Medicare and the suppliment would have paid. Its the Therapies problem that services started before everything was done properly, not yours.
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Reply to JoAnn29

This IL has a rehab unit within the IL??
Thats very much not the norm.
IL don’t usually have any on site PT or OT. Perhaps a fitness center or exercise/ activities room at he IL. And perhaps why the paperwork didn’t follow the usual pattern.

Whatever the case, your mom got a professional service and she kinda needs to do whatever so that the vendors can bill the insurers. Have her (not you) sign the paperwork. If it comes back denied, then she’s going to need to do an appeal and start to private pay the bill while the appeal runs its course.

This event could be the RED FLAG for you as her DPOA that your mom is not competent and cognitive to be in IL but needs to move to a higher level of care like AL or a NH. If she’s in IL, she’s fully expected to understand what she agrees to; that it’s up to her to verify coverage; to understand what she has for insurance; what medications she needs to take, etc. She’s independent living, she’s supposed to be cognizant.

Your post reads that she chose to discontinue therapy. Please realize if so, this likely gets recorded in her chart as “non compliant for care”. Noncompliant is her choice but there could be fallout from this..... like if she needs care or therapy and it’s the very same ICD-10 codes that she got & was noncompliant on, the insurers may not pay till it’s a period of time - like months - from her old noncompliance. If this happens, it will be very very co$tly and she won’t have a lot of recourse against the insurance company if they follow a noncompliance clause. This is serious, noncompliance has consequences.

If your mom has traditional medicare and a better 2ndary health insurance (like a high option BCBS), then rehab after a hospitalization will be covered benefit. So between the 2, there should be coverage & maybe a small copay at worst.
But if there was no hospitalization, then usually Medicare will cover 80% of the Medicare negotiated rate. The other 20% is from the secondary insurance or private pay. This assumes the rehab center and therapists participate in MediCARE and 2ndary insurer. The PT, OT do not have to participate with Medicare or all insurers. If that’s the situation, it will be private pay and I’d suggest you try to find out soon to try to negotiate a lower bill more in line what medicare pays AND before bills go out.

Really please pause to think if mom needs a higher level of care.
Admissions at the IL should have someone they know who can do a needs assessment on your mom. It might be worthwhile to pay to get an assessment done on your mom.
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Reply to igloo572

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