Norma is 90; fell and broke her back. Kaiser wants to kick her off skilled nursing after just 2 weeks of rehab. What are points we should make in our appeal letter?
You all deserve a more complete answer. We received the notice late afternoon that we only had until noon the next day to appeal or payments would be cut for Norma at the Skilled Nursing Facility, that charges $500+ a day. Turns out that they dont have to give a reason until you appeal. What worked was to phone the appeals agency early in the morning and say we plan to appeal, and asked for their reasons. That way we would have time to respond specifically. We learned that they had the misconception that Norma didn't get sufficient PT and OT to qualify. The statute calls for a week of PT or OT the agent wrongly claimed she needed both everyday. (which she actually is getting!) The therapists sent in their data and my wife threatened the agency with a suit for neglect if Norma's condition worsened. And they called to inform us that they withdrew their denial. whew. The tip I'd like to leave here is that its worthwhile trying to head off the denial.
My wife and I jumped on the internet and found a number of sites, such as this one, that offered tips..
Thanks everybody! We used some of the suggestions here and got them to rescind their order. Turns out they were acting on sparse and incorrect data, YAY!! hjnoble
They will kick someone off when they are not making progress; that meaning no matter how long they stay in that setting they are unlikely to improve. Appeals are usually unsuccessful, and they will have sufficient documentation done to show that further time there will be of no benefit to the patient. That they should now move to LTC. I am afraid you will have to face this, if not now, very soon, so make clear to Social Worker that LTC is likely what you will need to get. So just a warning, whatever you do it is unlikely to make a difference. Your best argument is that SNF actually IS improving the condition of Norma; that you are seeing positive change, but due to advanced age it may seem slow to others. You second best argument is that, if Norma improves further she may get to return to independent living with family support, rather than long term care, and you are pleading for this chance for her. I can't really think of other things that might work. Are there other problems? Bedsores or anything? As I said, be prepared; this may not work. But your argument must be THIS IS WORKING but seems slow due to AGE, and PLEASE give her this chance. Good luck. Hope you'll update.
AlvaDeer you're unfortunately correct. Getting kicked off in spite of Jimmo vs. Sebelius 2013, and federal laws mandating to maintain therapies to keep a person from declining. Also, facilities will revoke therapies quoting an outlawed never existing "not making progress," excuse. The number of times that our facility revokes therapies for Medicare or Medicaid recipients is horriffic. The facility will contact a resident's doctor to get orders revoked, claiming resident X isn't "making progress," and thus isn't needing therapies. Docs will in turn blame the resident/patient. It's unethical and violating so many basic decency protocols. The facility will claim, that Medicare and/or Medicaid isn't paying. Which is false ... also the facility will threaten eviction if the resident obtains therapies off-site. It's all about money $$$$$$.
Is this a Medicare Advantage? Because things work different with an Advantage than straight Medicare with a suppliment.
For me Medicare is my primary and BC/BS is my suppliment. Medicare determines how long a person stays in rehab and the supplimental pretty much goes along with Medicare.
"Medicare Advantage is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D. Plans may have lower out-of- pocket costs than Original Medicare. In most cases, you'll need to use doctors who are in the plan's network."
"Medicare Advantage is also known as Medicare Part C. It is technically still a part of Medicare, but it is not sold or managed by the federal government. ... While all plans must cover the same services as Parts A and B, different Medicare Advantage plans will have different networks, copays, and drug formularies.Jan 6, 2020"
This is why I will not have an Advantage plan. They have too much control.
Is Norma inside an Intense Rehabilitation Facility or a Skilled Nursing Facility? In the U.S. Norma should have both Kaiser and Medicare, since Norma is 90 she would have qualified for Medicare at age 65.
To formulate an appeal letter, the writer would need all of Norma's relevant medical records, to discern in which section of her spine Norma experienced a breakage. If it's cervical, then her rehabilitation will be a bit different than if she broke her spine in her thoracic region.
Also the writer would need Norma's facility physical therapy records. to discern if Norma has been getting better during her rehabilitation stay. Don't utilize the invalidated phrase "not making progress," (Jimmo v. Sebelius) in the appeal letter unless you are utilizing that invalidated phrase as an example of outdated (invalid) excuses for terminating payments.
The writer will need to ask Medicare what Medicare has been paying and what will Medicare pay (cover), if/when Kaiser abruptly stops paying.
Her doctor (orthopedic) will provide her prognosis and information about what is needed for her rehabilitation. Minimally Norma will need ongoing muscle strengthening and stretching. Did Norma have surgery, or not?
All in all the appeal letter will depend upon her medical records and current physical status. in the end, Norma must stay mobile or she will deteriorate.
Sidebar: Unfortunately, U.S. Skilled Nursing rehabilitation facilities provide bare minimum maintenance, they'll often leave patients to deteriorate in spite of doctor's orders, to save $$$. Remember it's all about money, in every part of U.S. "healthcare."
What worked was to phone the appeals agency early in the morning and say we plan to appeal, and asked for their reasons. That way we would have time to respond specifically. We learned that they had the misconception that Norma didn't get sufficient PT and OT to qualify. The statute calls for a week of PT or OT the agent wrongly claimed she needed both everyday. (which she actually is getting!) The therapists sent in their data and my wife threatened the agency with a suit for neglect if Norma's condition worsened. And they called to inform us that they withdrew their denial. whew.
The tip I'd like to leave here is that its worthwhile trying to head off the denial.
My wife and I jumped on the internet and found a number of sites, such as this one, that offered tips..
YAY!! hjnoble
So just a warning, whatever you do it is unlikely to make a difference.
Your best argument is that SNF actually IS improving the condition of Norma; that you are seeing positive change, but due to advanced age it may seem slow to others.
You second best argument is that, if Norma improves further she may get to return to independent living with family support, rather than long term care, and you are pleading for this chance for her.
I can't really think of other things that might work. Are there other problems? Bedsores or anything?
As I said, be prepared; this may not work. But your argument must be THIS IS WORKING but seems slow due to AGE, and PLEASE give her this chance.
Good luck. Hope you'll update.
Also, facilities will revoke therapies quoting an outlawed never existing "not making progress," excuse.
The number of times that our facility revokes therapies for Medicare or Medicaid recipients is horriffic. The facility will contact a resident's doctor to get orders revoked, claiming resident X isn't "making progress," and thus isn't needing therapies. Docs will in turn blame the resident/patient. It's unethical and violating so many basic decency protocols.
The facility will claim, that Medicare and/or Medicaid isn't paying. Which is false ... also the facility will threaten eviction if the resident obtains therapies off-site.
It's all about money $$$$$$.
For me Medicare is my primary and BC/BS is my suppliment. Medicare determines how long a person stays in rehab and the supplimental pretty much goes along with Medicare.
"Medicare Advantage is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D. Plans may have lower out-of- pocket costs than Original Medicare. In most cases, you'll need to use doctors who are in the plan's network."
"Medicare Advantage is also known as Medicare Part C. It is technically still a part of Medicare, but it is not sold or managed by the federal government. ... While all plans must cover the same services as Parts A and B, different Medicare Advantage plans will have different networks, copays, and drug formularies.Jan 6, 2020"
This is why I will not have an Advantage plan. They have too much control.
In the U.S. Norma should have both Kaiser and Medicare, since Norma is 90 she would have qualified for Medicare at age 65.
To formulate an appeal letter, the writer would need all of Norma's relevant medical records, to discern in which section of her spine Norma experienced a breakage. If it's cervical, then her rehabilitation will be a bit different than if she broke her spine in her thoracic region.
Also the writer would need Norma's facility physical therapy records. to discern if Norma has been getting better during her rehabilitation stay. Don't utilize the invalidated phrase "not making progress," (Jimmo v. Sebelius) in the appeal letter unless you are utilizing that invalidated phrase as an example of outdated (invalid) excuses for terminating payments.
The writer will need to ask Medicare what Medicare has been paying and what will Medicare pay (cover), if/when Kaiser abruptly stops paying.
Her doctor (orthopedic) will provide her prognosis and information about what is needed for her rehabilitation. Minimally Norma will need ongoing muscle strengthening and stretching. Did Norma have surgery, or not?
All in all the appeal letter will depend upon her medical records and current physical status. in the end, Norma must stay mobile or she will deteriorate.
Sidebar: Unfortunately, U.S. Skilled Nursing rehabilitation facilities provide bare minimum maintenance, they'll often leave patients to deteriorate in spite of doctor's orders, to save $$$. Remember it's all about money, in every part of U.S. "healthcare."
That is important to know but, based on what is written I would think it is an Advantage plan and that means that you DO NOT have Medicare.
Stick around for more suggestions.
Best wishes to you.