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?
you can find the answers to most of your questions by going to http://www.cms.hhs.gov/manuals look under medicare benefits policy manual 100-02, then under snf.
read sections 30: skilled nursing facility level of care (around page 17 of the manual). read section 30.6, daily skill services defined.
and section 40, physician certification and recertification.
before the skill can bill patient for services, they must get the patient or patient representitiveto sign they have been made aware that skill services will no longer be covered. i believe this is called a notice of non-coverage. if this was signed, you may have to pay the bill. on the back of your grans medicare notice, there will be information concerning steps to take if you don't agree with the bill. if she want an appeal she (or a family rep) must request in writting or call that number provided. there may be a time limit, so pay attention to that detail. appealing is nothing new, it happens all the time. the intermediary will contact the snf and request they send the patient medical records to the intermediary that handles the medicare service and a nurse will do a clinical audit to determine if the patient still needed skill or if the snf was at fault. the first thing the nurse auditor will look at will be the written notice of non coverage to make sure it has been signed and dated by the patient or patient rep and every detail is in order.
if medicare (the contracted intemediary) agrees that skill was necessary, and all the dates are within the medicare limit, you should not be billed.
Specializes in LTC,Hospice/palliative care,acute care.
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. >>>>>>>Sadly unless you have a one to one ratio of cna's to residents someone sometime has to wait.. >>>>>>>>>
I wish there was more that could be done to change this all.
ASSEDO
201 Posts
you can find the answers to most of your questions by going to http://www.cms.hhs.gov/manuals look under medicare benefits policy manual 100-02, then under snf.
read sections 30: skilled nursing facility level of care (around page 17 of the manual). read section 30.6, daily skill services defined.
and section 40, physician certification and recertification.
before the skill can bill patient for services, they must get the patient or patient representitive to sign they have been made aware that skill services will no longer be covered. i believe this is called a notice of non-coverage. if this was signed, you may have to pay the bill. on the back of your grans medicare notice, there will be information concerning steps to take if you don't agree with the bill. if she want an appeal she (or a family rep) must request in writting or call that number provided. there may be a time limit, so pay attention to that detail. appealing is nothing new, it happens all the time. the intermediary will contact the snf and request they send the patient medical records to the intermediary that handles the medicare service and a nurse will do a clinical audit to determine if the patient still needed skill or if the snf was at fault. the first thing the nurse auditor will look at will be the written notice of non coverage to make sure it has been signed and dated by the patient or patient rep and every detail is in order.
if medicare (the contracted intemediary) agrees that skill was necessary, and all the dates are within the medicare limit, you should not be billed.
hope this helps.