Complaint got my gram bumped from Medicaid pay to self pay!

Jo Dirt · Jul 23, 2007

After having to deal with my 82 y/o father-in-law on this issue, what my husband and me were told by social services (and the internet) is Medicare is what pays for the 100 days in a nursing home plus OT and PT, after that they have to "qualify" for Medicaid, meaning they must have exhausted all resources (property, savings, stocks, etc.) down to $2200 before Medicaid will pick up the bill. I assume your grandma already had medicaid, though.

I know Medicare is part of the entitlement program for old people so I'm pretty sure they cannot deny payment. Medicaid, on the other hand, is considered welfare for the destitute and needy and they have indeed cut people off for complaints (to them it looks like the patient was capable of refusing care and therefore was not in bad enough need of the services)or if one of their reps review a medicaid patient's chart and determine they do not need the services they are receiving. I work with private duty medicaid patients and many families mistakenly assume medicaid is something they are entitled to and are shocked when they get a letter in the mail informing them funding from medicaid has ceased after they have filed a formal complaint. I'm not saying this is right but this is how they see it. I personally know a family who refused certain nurses and a couple of months later got a notice and a bill for over 10grand for the services the patient received after they began refusing nurses. As far as I know they are still obligated to pay.

EmmaG, RN · Jul 23, 2007

Check this out http://www.medicare.gov/Basics/appealsoverview.asp

Edit: you mention both Medicaid and Medicare in your post. I'm not sure if that is a mistake or if you mean both are being denied.

The above link is for Medicare appeals. But I'd first contact the ombudsman at the link I posted below.

Here's the one for the state medical assistance: http://www.dhhs.nh.gov/DHHS/AAU/default.htm

EmmaG, RN · Jul 23, 2007

This too (I'm going by your location on your profile) http://www.dhhs.state.nh.us/DHHS/OLTCO/default.htm

kukukajoo, LPN · Jul 23, 2007

thank you so much! I will be on the phone tomorrow for sure! It is such a hard thing to deal with.

She is supposed to have 100 days covered as long as there is room for improvement which there is plenty room for improvement and could get other docs to attest to. I will certainly be contacting them as well.

I am disappointed with the facility and very discouraged. It seems to me that this is not the first time they have done this to anyone and they were really good at the deflection and the CYA game. You know, all I wanted was an apology and to make sure it did not happen to others or to my gram again.

I have spoken to three individuals who have loved ones pulled from the place, and one in the process of moving another due to other alarming instances.

I did make a mistake- I meant medicare, not medicaid. She does not qualify for medicaid. I keep getting the two confused.

You know, I am really disgusted at how the elderly are treated! When she first went into the hospital I had to have a locksmith come out as her apt. door would not lock due to a very worn part. The on site management at this complex is not there and it is an elderly building. Well they refused to pay the bill for the emergency service and tried to tell me that the reason the door was not locking was due to a light being left on in her apt!! I told this to the locksmith and to the fire inspector and they both said to tell them it may be time for them for a full inspection if the electrical would screw up locks like that! I think it's just a line they give the elderly!!

Jolie, BSN · Jul 23, 2007

I know Medicare is part of the entitlement program for old people so I'm pretty sure they cannot deny payment.

Unfortunately, this is not entirely true. Medicare does pay for a limited number of skilled nursing days under very specific circumstances. For example, the patient must have had a recent hospital admission related to the medical or surgical (not mental health) condition for which they are being admitted to a skilled nursing facility. The patient must require a certain number of hours of skilled nursing care per day, or must require skilled therapy (PT, OT, ST, etc.). The patient must actively participate in these therapies and treatments, and must be showing evidence of continued improvement in order for Medicare to continue payment. If a patient refuses to participate in therapy, or his/her progress stalls, Medicare can and will end payment for skilled care.

We cared for Hubby's elderly aunt, who lost her eligibility for Medicare funding of her skilled care (following a hip fracture) when she began to refuse daily PT. We were notified by Medicare of the impending cutoff of her payment, and had to arrange for private pay until she was able to be DC'd home. We were not given a lot of notice (I think it was about a week), but nor did they cut off payment without notifying us. In Auntie's case, it was not a matter of a battle with the nursing home, as we knew that Auntie was not cooperating with her treatment plan.

It sounds like the nursing home you are dealing with has not been above board regarding your Gram's eligibility for Medicare, and has not been cooperative in providing documentation necessary to qualify for continuing Medicare payment. In that case, their social worker would probably not be helpful to you. Is there a hospital social worker, or a social worker in private practice who could guide you in appealing these payment decisions to Medicare? Perhaps a family law attorney could advise you in how to protect Gram from collection proceedings while you sort out her financial obligations.

Sorry to hear of such problems. Bless you for taking such good care of your Gram!

woody62, RN · Jul 23, 2007

There is an appeal process you can undertake with Medicare. Since this place has been having problems, you need to file a complaint with your state agency that monitors facilities for complancy with Medicare regulations. You need to write out just what happen, naming the individuals involved, as well as the administrators whom you spoke to. They will investigate. You also need to contact N.H. ombundisman for the Elderly. Every state has them and they do look into situations like the one your gram was in. And I suggest you write a letter to your state sentator and state representative, inclosing a copy of your complaints to the other agencies. And let these agencies know you are notifying your state representatives.

Last summer, I was in a nursing home for wound care management. I got out of my wheelchair and pasted out. I ended up in an ICU for 21 days, with acute renal failure and sepesis. When I was discharged back, they had me sign a paper saying I wouldn't sue them. I signed it and then notified the Florida agency that monitored nursing homes. I was told that it was highly unlikely that the form would hold up in court. Shortly after I made my complaint, I was discharged. Fortunately I was well enough to go on home care.

Woody

kukukajoo, LPN · Jul 23, 2007

I am so sorry that happened to you woody! That is just awful and it seems more widespread than anyone thinks.

I will contact the legislators- one lives just around the corner and I know several personally. I wonder what they can do to help me and more importantly that this does not continue to happen to others.

woody62, RN · Jul 23, 2007

I am so sorry that happened to you woody! That is just awful and it seems more widespread than anyone thinks.
I will contact the legislators- one lives just around the corner and I know several personally. I wonder what they can do to help me and more importantly that this does not continue to happen to others.

It is more wide spread then many people think it is. And it has been going on for years. During the 70's I was a fraud and abuse investigator for the New York State Department of Health, in New York City. I went on several site visits to nursing homes in the city. And left boiling mad at what I had seen. NYS changed their rules but the nursing homes found other ways to scam money from the tax payers and not provide the quality of care we all expect. I will be 62 in three weeks. I pray that I die in my sleep, when my time comes. I don't want to spend my final days in a nursing home.

Please notify your legislaters and anyone else you can think of. And by the way, you are not responsible for the unpaid portion of your grams bill. The worse they can do is get a judgement against her. And that can't be collected until after she dies, which hopefully will be a long and happy time away.

Woody

TrudyRN · Jul 23, 2007

This is just shocking. I shouldn't be shocked but am, nevertheless.

I think a good lawsuit might work wonders. Half kidding. Better probably to try to work it out through the Ombudsman and Medicare Appeals, maybe JCAHO, your state rep and senator, as suggested. Maybe your County or city has a department that deals with elderly well-being.

Private agencies, like various family and children's services, be they Lutheran, Jewish, Catholic, etc. might have a social worker you can talk to for guidance.

This sounds pretty outrageous and very wrong.

And if a patient refuses to participate in therapy, is it due to pain, depression, some other medical reason that should be addressed?

Absolutely do be specific about your Gram knowing the meds were wrong and that's why she refused them. Or maybe you have to portray her as too out of it to have refused. The place sounds like a hell hole.

TrudyRN · Jul 23, 2007

There is an appeal process you can undertake with Medicare. Since this place has been having problems, you need to file a complaint with your state agency that monitors facilities for complancy with Medicare regulations. You need to write out just what happen, naming the individuals involved, as well as the administrators whom you spoke to. They will investigate. You also need to contact N.H. ombundisman for the Elderly. Every state has them and they do look into situations like the one your gram was in. And I suggest you write a letter to your state sentator and state representative, inclosing a copy of your complaints to the other agencies. And let these agencies know you are notifying your state representatives.
Last summer, I was in a nursing home for wound care management. I got out of my wheelchair and pasted out. I ended up in an ICU for 21 days, with acute renal failure and sepesis. When I was discharged back, they had me sign a paper saying I wouldn't sue them. I signed it and then notified the Florida agency that monitored nursing homes. I was told that it was highly unlikely that the form would hold up in court. Shortly after I made my complaint, I was discharged. Fortunately I was well enough to go on home care.
Woody

Why did you sign?

nell · Jul 23, 2007

And if a patient refuses to participate in therapy, is it due to pain, depression, some other medical reason that should be addressed?

Yeah.:angryfire

Is there no such thing as patient rights if you are old/on Medicare/on Medicaid?

I am truly disgusted.

nell