Follow
Share

My mom recently spent two weeks in a psychiatric hospital due to dementia aggravated by behavioral issues and was released to a skilled nursing facility after being denied at two assisted living communities. She was placed on the rehab hall and my sister and I were told that Medicare would pay 100% for 21 days then we would have a copay. Now, the nursing home has told us that since Mama came from the hospital with only a diagnosis of dementia, Medicare is only going to pay for 14 days total. My mom has COPD, chronic high blood pressure, and has now been diagnosed with diabetes. A recent MRI indicated that she's had mini strokes. I collected billing information from two doctors and one neurologist and presented it to the finance director at the nursing home but was told it may not make any difference. My sister and I are new to all of this and hope we have some recourse to get Medicare to pay for as long as possible before private pay kicks in.

This question has been closed for answers. Ask a New Question.
Vicky, do you know the specific diagnosis for which your mother was sent to rehab? Was it medical or psychiatric related? The facility should be able to tell you this; it will be on the hospital referral.
Helpful Answer (0)
Report

The 21 day rehab benefit usually gets done as the scenario is that elder falls, breaks a hip, goes into hospital, has surgery & then discharged to rehab. 21 days is the benchmark amount of time for pT, OT, etc to determine IF they are progressing in their rehab from hip surgery. If so, then Medicare can continue paying the rehab benefit (at 80%). But if not, it stops.

But for your mom, if it's mainly a psych rehab referral, I'd bet rehab was all about needing to get her meds figured out. And 14 days may be the standard. If she was good on her ADLs then there's no PT, OT rehab needed to get rehab extended beyond 14. You might want to look at the ICD codes and diagnosis from her doc that was put in her chart. I'd bet that If it reads medication management, then once that's figured out, she's out of any Medicare post hospitalization benefit.

The co-mobidities she has (copd, diabetes) weren't the reason for psych hospitalization. So not included as a factor ir rehab. 

It may be that mom will just need to private pay till she's at the point of being eligible for medicaid. If mom has assets it would be well worth meeting with an elder law to discuss what could be options for mom. Also clearly speak with her current facility regarding if they take Medicaid. If she needs a secure ward, the beds in that section may or may not be medicaid beds.

It's going to be a lot to deal with. Stay organized & take time for yourself so you dont get too overwhelmed
Helpful Answer (1)
Report

Appeal the decision by filling out the form provided with your Mother's EOB. Do this on a timely basis.
The facility is the biller to Medicare. As the patient, your mother should still be getting an EXPLANATION OF BENEFITS in the mail from medicare. The form to appeal is included with the EOB.

Just received one today. The doctor's office billed it wrong to medicare. Even though it is not my job to correct their errors, I will appeal it. All I need to say, to answer the denied charges: "My husband is not a new patient, this is obviously billed incorrectly."  

I do want my hubs doctor's to get paid. But, it falls to me to correct someone else's errors.
Helpful Answer (0)
Report

First, hugs to you and your sister. This is such a challenging position to be in.

Medicare does not pay for residential care at all, except for brief temporary periods to improve some condition so that the person can return to their own residence. This temporary period may be in a transitional care unit (tcu) or in a rehab facility, either a stand-alone building or a wing of a nursing home. Medicare has their own rules for determining the length of "temporary" in various circumstances.

Your mother has already spent time in a psychiatric facility. I hope that they were able to come up with medications and a treatment plan for the behavior problems. Unfortunately people with dementia can not live alone, so some long-term living arrangement must be made. There really isn't much "rehab" applicable to dementia. If someone with dementia has to learn to walk with a walker and regain some strength, rehab can help. But the dementia itself? Not much.

Would Mom need rehab for her COPD? For diabetes? For any condition she has? Otherwise the Medicare guidelines probably cover a short stay. By all means, be sure the finance director submits your additional information, but don't get your hopes up.

Where will Mom go next? Stating in a rehab wing probably doesn't make sense long term no matter who is paying for it.

Will Mom be able to pay for whatever comes next? If not, ask the finance director to provide you with Medicaid information. They do pay for residential care. Mom has to qualify, and it may be to your advantage to pursue the application with the help of an Elder Law attorney, especially if her financial situation is complex.

I am so sorry you have to deal with this along with the pain of dealing with the dementia.
Helpful Answer (2)
Report

This question has been closed for answers. Ask a New Question.