Federal courts in Pennsylvania and Vermont have ruled that Medicare standards are too stringent when it comes to deciding if a patient is eligible for skilled nursing home care or home health.
The Federal District Court in Pittsburgh disagreed with Medicare's decision to terminate coverage of an 81-year-old woman who required skilled nursing care, physical therapy and occupational therapy in a nursing home after a hip replacement. After five weeks of treatment, Medicare ended her coverage claiming that she had not improved and wasn't likely to. In the Vermont case, Medicare terminated coverage of a 66-year-old woman who was getting home health services after suffering from two strokes. The federal court there ruled that Medicare improperly denied the woman coverage. Her lawyers argued, successfully, that home therapy was needed to keep her condition from deteriorating, The New York Times reported.
Following these two rulings, 17 House Democrats wrote President Obama a letter asking for more relaxed standards.
Working in healthcare, I am used to insurer scrutiny of care, length of stay, etc. but this one caught me by surprise as I am not used to hearing about Medicare clamping down in this way. Sure they have standards and protocols but it seems in these instances they were jumping to care conclusions when maybe it was not their place to do so.
In any case, lesson is to not be caught surprised by what your insurer will or will not cover. Verify. And if after the fact you are not satisfied enlist the services of a patient advocate to health. No one will fight for your healthcare except you.
The Federal District Court in Pittsburgh disagreed with Medicare's decision to terminate coverage of an 81-year-old woman who required skilled nursing care, physical therapy and occupational therapy in a nursing home after a hip replacement. After five weeks of treatment, Medicare ended her coverage claiming that she had not improved and wasn't likely to. In the Vermont case, Medicare terminated coverage of a 66-year-old woman who was getting home health services after suffering from two strokes. The federal court there ruled that Medicare improperly denied the woman coverage. Her lawyers argued, successfully, that home therapy was needed to keep her condition from deteriorating, The New York Times reported.
Following these two rulings, 17 House Democrats wrote President Obama a letter asking for more relaxed standards.
Working in healthcare, I am used to insurer scrutiny of care, length of stay, etc. but this one caught me by surprise as I am not used to hearing about Medicare clamping down in this way. Sure they have standards and protocols but it seems in these instances they were jumping to care conclusions when maybe it was not their place to do so.
In any case, lesson is to not be caught surprised by what your insurer will or will not cover. Verify. And if after the fact you are not satisfied enlist the services of a patient advocate to health. No one will fight for your healthcare except you.
4 comments:
I really liked this post. You write about this topic very well.It must be one of the things to be given importance when caring for an elderly individual. I really like your blog and I will definetly bookmark it! Keep up the super posts! :)
Medicare Nursing Home Country Club
Another great post, Anthony. I have quietly been following you for sometime, but you have put up two posts this week that I feel I can intelligently comment on! So here goes . . .
Often nursing homes may mistakenly require a resident to be improving or showing progress in order to continue skilled services and maintain her Medicare coverage. If a resident “plateaus”, or the nursing facility says the resident no longer has rehabilitation potential, the facility may deny her further coverage. Denying Medicare coverage for this reason is improper.
The Medicare regulations are clear that “restoration potential” is not a valid reason for Medicare coverage denial. Other regulations provide coverage for “maintenance programs based on initial evaluations and periodic assessments”. The court cases you cited prohibit the use of “rules of thumb” and require individual assessment of an individual’s needs.
Unfortunately, the “improvement standard” has wriggled its way into the system and is improperly applied at all levels, from nursing homes to the appeals level. One reason may be that there are so few advocates who are aware of the rules and who have the skills to appeal a coverage denial.
The two cases discussed, relying on the regulations I mentioned above, held that Medicare can pay for skilled care if it is needed simply to preserve a patient's current functioning or prevent further decline.
I think we'll see more like those cases (with the Medicare beneficiaries winning) until the administration takes an explicit stance.
Bob - thanks again. So is it the nursing facility at blame or Medicare?
I hesitate to lay too much blame on what may be just "misinformation" . . . if I were to point anywhere, I'd probably point at Medicare/CMS for not simply putting out a clarification to the nursing facilities. The last thing the facilities want is to have a Medicare reimbursement denied . . . or recouped in an audit . . . so I hesitate to come down on the nursing homes.
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