Reply to Please help! Medicare Part A SNF facility coverage after hosp for long term care patient

Forum Index » Eldercare

Reply to "Please help! Medicare Part A SNF facility coverage after hosp for long term care patient"

Subject:

Emoticons





More smilies

Text Color: Font: Close Marks

[quote=Anonymous]Dear Midlife Concerns Forum,
First, a big thank you to this forum group for not having as much of that snark that seems to have taken over the other DCUM forums. 
I've read a lot but I still do not understand how long Medicare Part A coverage should pay for a snf stay after a repeat hospitalization.  Everyone seems to think the way the system "really" works in real life is different from what the Medicare regs say.
Parents have Medicare and Tricare For Life, live in a nice continuing care community in TN. When they moved there they had to pay in advance for 360 days of snf care. 
As the pandemic began, dad developed sepsis from an open would from a skin cancer surgery.  Management of CHF was a big part of the hospitalization.  Got discharged and went to snf bed in complex where he lives.  Facility billed him for 100 days of post-hospitalization snf care, which was covered by Medicare w Tricare helping, and then Tricare paid for several more months of snf care, ending last September. 
At this point I accepted at face value the facility’s explanation that Medicare would only pay for “skilled nursing” while OT and PT were making sufficient progress to justify 5 day per week service.  Now I have read about the Jummo settlement where CMS agreed the need for PT/OT depends on the patient’s need for skilled services, which may be simply to avoid decline rather than continued progress.  
Dad used his prepaid days until year end, then resumed using prepaid days in 2021.  While using the prepaid days he was getting skilled nursing every day due to his need for close monitoring of fluid levels, constant adjustment of diuretics, pressure injuries, arthritis and gout.  Wheelchair bound.  Got PT/Ot a few times a week and was supposed to get non-skilled movement care on other days but short staffing due to covid made that not happen.  
He got covid from a caregiver in February and they moved him to the covid floor and declared he was in “skilled nursing” care for a couple of weeks.  Snf billed Medicare for this as “inpatient.”  We are not yet 100 days past that date, even if it should have started a new 100 day period (should it have?). 
He moved back to regular room, using prepaid days, much weaker.
Hospitalized in March due to mysterious injury on leg that became giant hematoma requiring surgery.  More tricky management of heart and kidney issues.
Discharged; given snf care with Medicare billed for several weeks, then facility said they had to stop billing Medicare bc he no longer needed skilled nursing because he had plateaued in PT and OT.  Ridiculous– he needs skilled nursing to watch his fluid levels and has been getting it all along, and he needs daily PT/OT with professionals to maintain his poor health, and he has a stage 4 wound.   
We just appealed the initial notice of Medicare noncoverage and lost.  Now we can appeal again.  Would it help to have his private practice doctors write a letter about his need for skilled nursing care?  The doctor at the snf described his condition accurately, although she didn’t say in so many words that he needs continued skilled nursing care.    
 I’ve read about Medicare changing the billing for PT/OT from RUT hourly to a balanced formula that makes Part A therapy bring in less money for facilities.  I’ve read about Medicare extending the 100 day period of coverage if covid caused delays.  I’ve read the Medicare manuals and the Jummo documentation.  I just don’t get the big picture, common sense side of this.  I know Medicare won’t pay more than 100 days after hospital discharge, but why can’t they pay those 100 days?  I basically trust the people working at the facility and I think they are being straight with me, but are they just wrong about Medicare coverage?  
Thanks!
[/quote]

Options

	Disable HTML in this message
	Disable BB Code in this message
	Disable smilies in this message

Review message

Search Recent Topics Hottest Topics