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

[kukukajoo]

My gram has been in a Nursing home since End of May and had her 100 days of rehab that was supposed to be covered by Medicaid fully for OT and PT. This would have run out second week of August.

Well there were many issues at this place and I finally had to call and complain after a nurse told my grandmother to shut up and someone tried to insist she take meds that were not her own. Of course this isn't considered an error because my gram was alert and aware enough to flat out refuse so nothing was done to even ensure this won't happen again to someone else!

Since that time I was supposedly notified that her care status changed (I wasn't) on July 3rd meaning they think she has improved as much as she will. This is a crock as she still can't climb steps or curbs and has not had any practice with it. She is getting a new brace on Friday that she will need to get used to.

The only meeting where I was made aware of any of this was last Friday (july 20th) which did not have a good outcome. Evidently after a orthapedist appt they never got the paperwork from the docs (they asked me that day for it and I called the office). having not heard anything since and being a very frequent visitor, I assumed this paperwork was there. Then they said it was faxed, but fax was blank- twice. Now this person was quoting stuff the ortho doc stated, so she HAD to have had it and read it but I can't prove it.

Then they go on and say that medicare won't pay for any of her outside docs appts and were acting like I had been bringing her to these appts without their knowledge or consent! I am so confused- beyond confused!

The meeting was supposed to discuss her progress and that was never ever discussed other than the PT said she would not classify her as needing PT or OT so medicare will pay for it! Her doc was not even present!

Top it off and today I get a bill for 5500 for July (partial) and 8500 for August!!

She is moving in with me on Wednesday- I can't wait to get her out of there!

My question is this- is anyone aware of any appeals of their change of status that I have available so Medicare pays for it? Anyone that can help me navigate this whole billing structure?

[muffie, RN]

good luck to you and gram, kukie

[kukukajoo, LPN]

Thanks everyone! Hi Muffie!!! Where have you been?

Gram is STILL getting the PT that she allegedly does not need! Also the bill that came in today had her at skilled level for billing purposes when they told me Friday she dod not need skilled or PT/OT anymore. Basically they are trying to jerk me around and poor gram is getting caught in the middle.

Funny, with all the issues at this place we have had, I had a great respect for their therapy team for all they had done for her. Now I wonder....

One more thing- They keep giving her spinach even though she is on coumadin and levels are unstable (jee I wonder why they dip?!) and had the audacity to copy a part of a info sheet from the manufacturer that says no need to change diet after I kept getting after them. It left off the part about avoiding spinach and the nurse even wrote on it to say that spinach was okay and signed it! I can't wait to turn that into someone. Glad I held on to it.

[EmmaG, RN]

One more thing- They keep giving her spinach even though she is on coumadin and levels are unstable (jee I wonder why they dip?!) and had the audacity to copy a part of a info sheet from the manufacturer that says no need to change diet after I kept getting after them. It left off the part about avoiding spinach and the nurse even wrote on it to say that spinach was okay and signed it! I can't wait to turn that into someone. Glad I held on to it.

Our nutritionist told me a few years ago that the thing now with Coumadin is to be consistent with your diet. For example, if you normally eat spinach (or whatever) a couple of times a week, just keep doing it. Don't drastically alter your diet in either direction. At least that is the diet teaching our patients were receiving.

'Course, you don't want to go crazy with it, either lol.

Edit: most sources I found echo this (the coumadin site is down right now):

However, dietary restrictions rarely succeed over a long period of time. Most patients return to eating their favorite foods, gradually at first. Thus the more prudent approach for Coumadin® maintenance is to adjust the medication, not the diet. That is one of the very reasons for repeating the Pro-Time until a steady dose is found that provides the right anticoagulation regardless of the dietary intake of the patient.

If your regular diet already contains these food items, Don't change your eating habits. Consistency in your daily eating pattern is the key. If you move to a new climate, or change your eating habits for any other reason, a new series of Pro-Times will be needed to make certain that your Coumadin® requirement has not changed. However, even if it has changed, the best option is to change the dose which you take.

[woody62, RN]

Why did you sign?

Would you believe the assistant administrator came into my room at 10PM, after I had been medicated for pain and told me she had some forms for me to sign. And I did something I have never done before, I signed them without reading them. I learned what they were for a few days later when a copy was given to me. The lateness of the hour and the fact that I had been medicated would more then likely gotten them tossed out in court. You see, there is a little thing about having a patient sign forms, when they are under the influence of a narcotic. Courts have held that statements made under such circumstances or releases signed, are not valid. We settled in nicely. They didn't bill me for the $4,000 in co-payments that they had charged me for. And I agreed not to sue them.:lol2:

Woody

[kukukajoo, LPN]

Yes, it says not to change your diet but it also says not too much leafy green veggies. She hasn't eaten them in years so it isn't wise and since she is having problems keeping her levels high and having to supplement at times with lovenox shots avoiding them would be a good idea according to her cadiologist. She just had a pacemaker and has other probs that could lead to clots so this is especially important as she already almost lost her leg from one.

Here is an excerpt from the fda.gov pt med guide & bristol meyers squibb the bolded area is exactly as it is written:

Some foods can interact with COUMADIN and affect your treatment and dose.

• Eat a normal, balanced diet. Talk to your doctor before you make any diet

changes. Do not eat large amounts of leafy green vegetables. Leafy green vegetables contain Vitamin K. Certain vegetable oils also contain large amounts of Vitamin K. Too much Vitamin K can lower the effect of COUMADIN.

Avoid drinking cranberry juice or eating cranberry products.

[Nascar nurse, ASN, RN]

Yeah.:angryfire

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

I am truly disgusted.

nell

When receiving medicare $$ for the purpose of receiving PT &/or OT therapy to regain physical functioning, it is not OK to repeatedly refuse to participate in such treatment and expect the tax payers to continue to pick up the bill. If you go into hospital for surgery and I (taxpayer) agree to pay for this and you continue to refuse day after day to go for surgery... why would I (taxpayer) keep paying for your room/board.

This is not to say that you don't have the right to lie in your bed and do as you please. You still have the right to pay privately for such services (room/board, nursing care, etc).. but medicare will not continue to pay for custodial care.

This is not to say that it medicare benefits can't continue for skilled medical needs, ie: pain management, adjusting medications to treat new depression, etc, but this gets very tricky and can easily cause payment denials it all is not documented just so.

Unfortunately hospital discharge planners don't understand all the medicare LTC regs and they are the first contact that most families get with this medicare maze. Then when the LTC attempts to educate, families think they are being deceived. It is not common to actually receive 100 days of medicare. We have an average medicare census of about 23 and our average medicare stay usually hovers around 30-35 days. Obviously by "average" some are going sooner and some stay longer.

To the original poster... This facility should have provided you with a "non-covered" letter with an explanation of why service was being terminated. Medicare is a federal program so it should be the same from coast to coast (where as medicaid is a state program and every state runs things differently). My facility uses a federal form called a "generic notice" (which is a non-covered letter). This notice should also include information of the appeals process and a phone number where you can call to get the appeals process started. If I remember right this is a time sensitive issue so don't delay. Walk into the facility and ask for this type of notice. They are required to prove that you were notified and/or prove that they made a reasonable attempt to get your signature of this letter.

Good luck

[txspadequeenRN, BSN, RN]

this is correct. in order to qualify for medicare placement in a skilled facility the patient must have three day hospital stay. they get days 1-21 paid for at 100% then days 22-100 are covered at 80% and the family is responsible for the other 20%. if they patient repetitively refuses care\therapy medicare will not pay for that and the patient in my experiences will be discharged. to the op sorry you are having such a hard time. i know how it is to take care of elderly parents. i have worked in skilled nursing for years and when my mom went in , even though i did the job day in and day out ,it was still a shock to deal with such mess....i hope you see better days . good luck to you

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.

[kukukajoo, LPN]

Thanks- I did get the letter- handed to me on Friday. Never saw it before then. Also the PT flat out refused to ever change her back, no matter what the docs recommendation was!!

Not sure where the refusal mentioned came from, but my gram has not refused anything except her roommate's meds (thank goodness!). She is mostly cooperative unless sitting there waiting for an aide to help her to the potty for 10-20 minutes.

Oh yeah- this facility feels 10 minutes to wait to check on a call light is fully acceptable. Is that normal? The way I look at is if we are paying $8500 a month for care, they should be jumping faster than someone sitting on a red ant hill.

Unfortunately the reality is that the place has staffing problems and uses many agency nurses and per-diem aides, etc. This is the norm and it affects quality of care and ratios are usually higher than they should be. Of course this is not just this facility, it is everywhere and very sad. The residents suffer and the employees as well who are stressed to the max so that they make mistakes like the med error and get short with the pts from being so stressed.

There is a huge shortage of beds in this area also. So it's a take it or leave it mentality.

I wish there was more that could be done to change this all.

[Nascar nurse, ASN, RN]

Unfortunately the reality is that the place has staffing problems and uses many agency nurses and per-diem aides, etc. This is the norm and it affects quality of care and ratios are usually higher than they should be. Of course this is not just this facility, it is everywhere and very sad. The residents suffer and the employees as well who are stressed to the max so that they make mistakes like the med error and get short with the pts from being so stressed.

I wish there was more that could be done to change this all.

Yep, unfortunately, I think this is the reality of a nursing home and it is pitiful! Staffing is always a huge burden. Extremely difficult job, little thanks from anyone, the pay generally is the pits (although from other posts, this doesn't seem true in all areas of the country), the staffing ratios are outrageous... (the reality is, sometimes a 10 minute wait for assist is pretty good. Not saying by anymeans that this should be acceptable.. but REALITY).

Until this society puts a priority on elderly care nothing will change. That is another sad reality.

[EmmaG, RN]

Yes, it says not to change your diet but it also says not too much leafy green veggies. She hasn't eaten them in years so it isn't wise and since she is having problems keeping her levels high and having to supplement at times with lovenox shots avoiding them would be a good idea according to her cadiologist. She just had a pacemaker and has other probs that could lead to clots so this is especially important as she already almost lost her leg from one.

Here is an excerpt from the fda.gov pt med guide & bristol meyers squibb the bolded area is exactly as it is written:

Some foods can interact with COUMADIN and affect your treatment and dose.

•

Eat a normal, balanced diet. Talk to your doctor before you make any diet

changes. Do not eat large amounts of leafy green vegetables. Leafy green vegetables contain Vitamin K. Certain vegetable oils also contain large amounts of Vitamin K. Too much Vitamin K can lower the effect of COUMADIN.

Avoid drinking cranberry juice or eating cranberry products.

Well, if she hasn't eaten them in years, then that would be a change in her diet which is what I was getting at--- be consistent. I wasn't too clear in that, sorry.

[EmmaG, RN]

Oh yeah- this facility feels 10 minutes to wait to check on a call light is fully acceptable. Is that normal? The way I look at is if we are paying $8500 a month for care, they should be jumping faster than someone sitting on a red ant hill.

I can always tell when a patient is from a nursing home such as this; they are the ones that call out, and as soon as you walk in room they start with rapid-fire requests for everything under the sun, because they are afraid they might not see you again for hours if at all.

Sad

[teeituptom, BSN, RN]

I can see your frustration.

I can also see where Universal Health Care would makem things more equitable. And would probably help this situation.