When does Medicare decide that a patient isn't making enough progress to continue paying for rehab?

Its the Medicare Advantage scam hard at work. They typically pay 21 days, yet to appeal, you’ll receive a NO. Try again, still NO. My Mum’s neuro stated (to Medicare) that my Mum would be able to return to her assisted living facility with another week to10 days of therapy, No again. Its a racket and the only way we will fix it is to work with attorneys and lobbyists to change the process. Medicare condemns our elderly to a life in a wheelchair, no dignity, its an awful system. And we all continue to pay for it.

Your loved one would need to progress to the point of being able to manage her needs on her own without assistance. If she can not progress to that level of independence, then you need to consider options that allow her to get the assistance she needs.

Sounds like your mom has hit a plateau, so no longer progressing in her post hospitalization rehab. If so, health insurance stops paying.

There’s 3 different paths for how Physical Therapy done & billable to health insurance. Like paid by Medicare and other health insurance she has for secondary / gap coverage or her Advantage Plan.
1. Post surgery in facilty rehab: therapy - PT, OT, ST - is in a facility - like a Nursing Home- as she is a post inpatient surgery hospitalization patient now discharged to a facility as a rehab patient. She will have specific codes for the aftercare rehab in her health chart. These are her ICD-10 codes with a baseline for care that insurers use. She is a rehab patient at the facility under health insurance coverage.

Like for hip replacement surgery (Z96.64 code), it’s after care therapy code is Z47.1 and it has a 3-6 week window for rehabilitation with a # of hours of therapy affixed to a code. For Original Medicare, their standard is first 20/21 days in a facility for rehab is covered 100% and then up to 100 days at 50%. That Z47.1 is the lead code, and it can have others added to it….. like M16.1 added means they also have osteoarthritis. All this is mucho importante as the codes set the standards for how long therapy done as a baseline average and what the benchmarks are for the type of therapy and if there are “extras” that can be taken into consideration (flexibility to the baseline). Like that M16.1 can add a bit as they came in with osteoarthritis; if T84.84XA they have existing pain issues so can factor into slower progress; M24 have other hip issues. All these tacked onto their health chart can give the PT some flexibility in the notes they have to post to the health insurer. PT in a NH has regular entries to the health insurer as to if patient is “progressing” with details or reached a “plateau” and again with details. If they hit a plateau and show no ability to progress for the code they came in on, then health insurance stops paying. You can do an Appeal. But really hard to get it approved as health chart shows why continuing would be a waste of time and in minute detail. Original Medicare does appeals by regions and turn around is pretty fast, maybe 72 hours, as already have the info the therapists entered.

2. As outpatient followup care. Same thing with the ICD 10 codes but the timeframe is wider as set # sessions over a # of weeks. It’s in a freestanding therapy place. PT doesn’t have to enter data quite as in real time as the PT in a NH rehab unit does.

For both of these, insurance coverage is geared to getting patient back to where they were before whatever happened to them that caused their surgery to happen. Has to be done in a fixed timeframe based on the codes.

3. Therapy for maintenance or to prevent decline. This as a Medicare benefit comes from Jimmo v. Sebelius lawsuit settlement. Jimmo is totally different than rehab for how insurers pay. Jimmo means if you are a custodial care resident (not a patient) then you can get PT & OT. Like 2 or3 times a wk 30min gait training on parallel track or hand strengthening on mini wheel. It’s targeted therapy. Medicare pays due to Jimmo.

Liz & RedMustard this - JIMMO - is what y’all are referring to; it’s not the same as post hospitalization rehab. Also used for those living at home who need regular therapy as have MS, are amputee’s, other chronic debilitating conditions. Jimmo was a brittle diabetic living in her home who had her out-patient PT cut off suddenly, so she filed lawsuit with MS & post polio & CP advocacy groups joining it.

Whatever the situation, elder HAS TO participate & be somewhat competent/cognitive to understand what therapists want them to do. If “maybe manana” when aides come by to take them 2 therapy, they won’t be forced to go. But will get discharged from being a rehab patient or left out of any Jimmo based billable therapy they could get as a custodial care resident.

You can speak directly to Medicare and should. Often times a person is 'downgraded' from rehab if the PT and OT claim that they haven't hit their milestones within a scheduled time frame. Usually the real reason is the rehab facility collected the maximum amount Medicare will pay in a short amount of time, so they push that patient out. Then bring in the next to maximize profits and keep this up one after the other. This would be why the PT is giving you the circular, run-around answer.

So here's what you do. Tell the PT to explain it to you in full detail (or get someone who can), demand to see the reports on how they're "tracking" your mother's progress, exactly how much rehab time she's given every day, and proof of how much they've collected from Medicare for her rehab services. Now, make yourself plain that either they can produce these things for you, or they will produce them for your lawyer. Their choice. You should absolutely be consulting a lawyer who specializes in elder law.

This is what I told the rehab my father was in. He suddenly became eligible for up to 100 rehab days. He received PT and OT for 30 days longer than they originally were going to give him.

When rehab and nursing home people give you circular, run-around answers it's usually because they're covering up some Medicare or some other kind of insurance fraud.

If Medicare no longer covers your mother, contest it. We received an additional couple of weeks doing that. And my mother was not doing anything. She just didn’t want to anymore. And she never improved. But we were trying to get her into LTC so every day Medicare covered her was one less day out of pocket until her Medicaid was approved.

The rehab social worker should be able to assist with this.

Rehab sends their notations to Medicare and then Medicare decides to continue coverage or not. She should have had a progress report done where the PT will explain to her how she was doing and if she is progressing or not.

Redmustardseed,

I found information you wanted and sent you a private message.

Medicare does not make the decision directly. Instead, the rehab facility is required to send regular progress notes and documentation to the Medicare contractor or the Medicare Advantage plan (if applicable). Based on that information, they determine whether the care continues to meet Medicare’s coverage criteria.

If Medicare or the rehab facility issues a Notice of Medicare Non-Coverage, she has the right to request a fast appeal. A patient advocate (sometimes called a case manager or discharge planner) at the facility can help her do that.

Go to Medicare.gov to a link called compare plans. Choose the plan she is on. It can be regular Medicare with a suppliment or an advantage plan which will state right on her card. When you compare plans about hospitals, rehab, emergency room and more, you will notice one governing factor with Medicare. All the plans will be the same. So that when our responses say 20 or 22 days of rehab, that is it at 100%. The family has to choose caring at home, finding LTC out of pocket or begin filing the Medicaid paperwork from which, once accepted someone can liquidate her assets. Remember if a home is sold or a car is sold at fair market value, she will come off of Medicaid until those assets are spent down on her care. Medicaid can be reapplied after she spends down again. If the home is to be kept with family, then they have to pay all taxes and utilities on their own because Medicaid takes all of her Social Security except for around $50 for personal needs.

Rehab sends the progress to Medicare. My dad never recovered from a broken hip. He platued. The stay with Medicare in skilled nursing was 30 days not the over 100 days he qualified for. It was the same situation with my mom. They tale you the last week that you need to find a place for them to live if you aren't able to take them home. They can usually have more PT in the future. You can try appealing the decision. My parents both had an expensive supplemental insurance too. Most of the time patients become immobile and are confined to a wheelchair.

Medicare doesn’t see anything until free the discharge and they can refuse to pay after the fact. There are very strict guidelines and the rehab will err on the side of caution regarding progress towards goals that were set at admission.

Medicare pays the first 20 days 100%. The next 21 to 100, 50%. That 50% has to be paid by the patient unless their supplimental or Medicare Advantage will cover it. So if rehab is $300 a day Mom will now be responsible for the other $150. This should have been explained to you when the admitting papers were signed. The papers should have had what Mom will owe if she goes over the 20 days. The 100 days is not a guarentee. Mom can be discharged at anytime. You should be having care meetings every so often.

Your Mom may never get back to where she was before. Her age will have a lot to do with how she progresses. It depends on how a hospital stay effected her. For a patient in their 90s, lets say, its...they are good till they aren't. Meaning a fall, pneumonia, etc can do them in even if they were doing for themselves before the hospital stay. Mom may hit a plateau where PT will no longer help her. Medicare will then have her released.

It would be very unusual to be granted more time as she has essentially used up the time allotted for rehab.
This is for you to discuss with the Rehab Social Workers and with the "discharge planning" committee, as places are unique to themselves and within the laws they operate differently.
But there is a running account and charting of progress made. And it is very clear how much can be made, and often futile to go on in rehab and will not be covered by Medicare past a certain point given the patient diagnosis and prognosis, age and general condition.

As I said, every case is individual as his or her own thumbprint, so speak with the rehab discharge planners, PT and OT. You should have been already invited into care planning if you are POA, or the person who IS POA/next of kin should be. This is for discussion between them. They can also explain government coverage for rehab.

Good luck to you.

Wow. I need to start using ChatGPT more often. That was very helpful to know that they don't have to continue to show improvement, but can also be approved to prevent decline or maintain!