Medicare appeal question - discharge from subacute rehab

[Anonymous]

For those who are knowledgeable, I’m trying to understand what I need to pull together to do a medicare appeal.

My elderly dad who has moderate dementia is in a subacute rehab facility in NJ following COVID in early August. While at the rehab facility he fell and hit his head, had a subacute hemorrhage and ended in the hospital for a few days before returning to the rehab facility. So now he actually is worse off than when he got ther originally, but he is slowly recovering. The facility plans to discharge him from subacute rehab to their long term care unit saying that “he has plateaued”. I understand to appeal the decision we are supppoesd to have a doctors note saying he needs the therapy. But how am I supposed to get a doctor to see him when he’s inpatient at a subacute facility? They have their own medical staff - and it’s the facility that seems to be giving up on him (which I’m pretty annoyed by since he fell on their watch.). I understand that a subacute hemorrhage can take several months to recover from. He’s sleeping a lot now because he’s recovering from both COVID and a head injury - but he still needs the PT and OT and speech therapy to try to get him back to the level he was at before COVID. We feel pretty stuck and confused on how to naviagate the system.

Appreciate any thought or other advice.

[Anonymous]

If I were you, I would take him to a doctor independent from the rehab facility, even if you need to make special arrangements. I did that for my Dad when I didn’t trust what the facility was telling me. Good luck

[Anonymous]

If he’s sleeping a lot and seems out of it, call an ambulance and get him to the hospital. Seriously.

[Anonymous]

read stuff on the center for medicare advocacy's website (search for plateau) or call them.

[Anonymous]

Read about Jimmo v. Sebelius.. Definitely appeal. We were told the first 2 appeals are ignored. 3rd minimum

[Anonymous]

To qualify he needs to be able to participate in a certain number of hours a day. Is he meeting criteria? Also is he progressing from an objective standpoint t?

If the answer is no to either question, then you don’t have a leg to stand on. But residents can move between levels of care. The good news is they are keeping him which makes that easier.

The bigger issue to me would be what level of therapy will he receive at LTC. There should be some and it might be more appropriate given that he doesn’t seem to be able to participate.

Last things. You only have a limited number of rehab days. Is this really how you want to use them? And if you lose the appeal, how will he pay because the facility will collect their money.

[Anonymous]

Anonymous wrote:If he’s sleeping a lot and seems out of it, call an ambulance and get him to the hospital. Seriously.

As someone whose Dad fell in a facility-THIS. Do this! Get him out of there, and after the hospital admission (it sounds like he would be admitted) have him sent elsewhere.

[Anonymous]

Anonymous wrote:To qualify he needs to be able to participate in a certain number of hours a day. Is he meeting criteria? Also is he progressing from an objective standpoint t?

If the answer is no to either question, then you don’t have a leg to stand on. But residents can move between levels of care. The good news is they are keeping him which makes that easier.

The bigger issue to me would be what level of therapy will he receive at LTC. There should be some and it might be more appropriate given that he doesn’t seem to be able to participate.

Last things. You only have a limited number of rehab days. Is this really how you want to use them? And if you lose the appeal, how will he pay because the facility will collect their money.

This is incorrect...

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement
agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors
were inappropriately applying an “Improvement Standard” in making claims determinations for
Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health
(HH), and outpatient therapy (OPT) benefits).

For example, in the regulations at 42
CFR 409.32(c), the level of care criteria for SNF coverage specify that the “. . . restoration potential
of a patient is not the deciding factor in determining whether skilled services are needed. Even if
full recovery or medical improvement is not possible, a patient may need skilled services to prevent
further deterioration or preserve current capabilities.

[Anonymous]

Anonymous wrote:

Anonymous wrote:If he’s sleeping a lot and seems out of it, call an ambulance and get him to the hospital. Seriously.

As someone whose Dad fell in a facility-THIS. Do this! Get him out of there, and after the hospital admission (it sounds like he would be admitted) have him sent elsewhere.

After a few days of sleepiness we took our relative back to the hospital from rehab.

Long story short: he needed emergency surgery for a brain bleed. He would have died had we not been proactive.

Are you in the dc metro area? Where, exactly? It matters.

[Anonymous]

Anonymous wrote:

Anonymous wrote:To qualify he needs to be able to participate in a certain number of hours a day. Is he meeting criteria? Also is he progressing from an objective standpoint t?

If the answer is no to either question, then you don’t have a leg to stand on. But residents can move between levels of care. The good news is they are keeping him which makes that easier.

The bigger issue to me would be what level of therapy will he receive at LTC. There should be some and it might be more appropriate given that he doesn’t seem to be able to participate.

Last things. You only have a limited number of rehab days. Is this really how you want to use them? And if you lose the appeal, how will he pay because the facility will collect their money.

This is incorrect...

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement
agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors
were inappropriately applying an “Improvement Standard” in making claims determinations for
Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health
(HH), and outpatient therapy (OPT) benefits).

For example, in the regulations at 42
CFR 409.32(c), the level of care criteria for SNF coverage specify that the “. . . restoration potential
of a patient is not the deciding factor in determining whether skilled services are needed. Even if
full recovery or medical improvement is not possible, a patient may need skilled services to prevent
further deterioration or preserve current capabilities.

Apologies to OP. The standard is improvement or prevention of deterioration. I was writing quickly. The remaining things I said stand - ability to participate and max days available.

[Anonymous]

I think people are missing the moderate dementia part. With moderate dementia, recovering from COVID, plus the sleepiness can he even participate in speech therapy, PT or OT? Will it really make a difference?

When my mom with dementia recently had COVID she slept too much and deteriorated. What helped was we hired an aide for 4 hours a day five days a week for 6 weeks to make her move and engage in life. They went for walks, looked at pictures together, ate together. Basically made sure she was out of bed so she got back some strength. Luckily it happened during summer so we were able to pay a college student $30 an hour.