Ever heard of this?? Medicare & AMA from LTC--> HH

  1. I had a pt I was seeing s/p cva. He was very forgetful and had trouble w impulse control, fell numerous times in the home. Finally, he was re-admitted as his poor wife was soooo tired, she could not see straight from staying up all night w him. He was in the hospital and had another CVA, so he went to a LTC/rehab. The family was very unhappy with this place, and the man's medicare benefit from the first time in rehab ran out, so the wife was having to pay out of pocket for everything. Family, and they are a wonderful and loving family, got together, and decided to bring dad home. Rehab refused to release him, and told family they would have to sign AMA, which means they would get no HH benefit.

    I have never heard of this before. The wife told me she thinks they did that b/c she had money, and they wanted her to pay the bill. I would be aghast if that were true, but after my fraud experience at the other place, absolutely nothing would surprise me like that, of course I didn't admit this to her. I just acted shocked at the thought, and told her I had never heard of this.

    I learned all this from the wife and dtr in the supermarket. They had called me several times about pulling him out and returning him home, and I had referred them to our Liason, who was waiting for the call from the CM. The wife told me they were told by my agency and several other agencies, that he would not be accepted for HH d/t the AMA status. Is this just b/c of Medicare? I mean we re-admit non-compliant pt's who sign themselevs out under Caid all the time, why should this family be punished like this? I really don't understand it.

    I plan to ask a few big cheeses at work to see if I can find out the scoop, but I was wondering if anyone here ever had an expereince like this.
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    About hoolahan

    Joined: Dec '99; Posts: 3,786; Likes: 129
    Quality Nurse & Home Health Nurse


  3. by   NRSKarenRN
    Rehab refused to release him, and told family they would have to sign AMA, which means they would get no HH benefit.[/QUOTE]

    No rule that I am aware of regarding no getting home health thru Medicare if signing out AMA. They are PRIVATELY paying for rehab cause his rehab benifit ran out...guess the Rehab physicians are forcing the AMA to cover their butts as they feel he is in need of more rehab treatment. This family wants to bring hime home. Tell them to ask for a care conference including rehab discharge planner or Social worker.

    Only problem as I can see it (apart of care issues) is who will sign the 485 plan of treatment (POT). Get the famly to contact patients Primary Care Physician (PCP). Have the PCP be updated by rehab staff---as long as the PCP agrees to sign the POT and family is willing to bring him home knowning the obstacles, I see no problem.

    He is also eligable for SNF stay, even if rehab benefit ran out as long as he has SKILLED needs; they will pay for 29 days 100% then decreases to no coverage after 100 days. If he has secondary coverage, that usually picks up the co-pay balance for the 100 days. After that own your home until income spent down to $2,000 when eligable for Medical Assistance.

    We accept AMA patients all the time with a PCP/referring doc agreeing to sign the POT. Patients have the right to refuse treatment at ANY time. AND they have often progressed faster in their own homes with adequate family support.

    SNF stays require 48-72hr hospital stay: no such requirement for Rehab and homecare.

    Only conditions for MC to pay for home care are:

    1. Patient qualifies for Medicare.
    2. Client must be under care of a physician. A plan of care is rendered under the guidance of a physician.
    3. Patient requires skilled nursing, occupational therapy, physical therapy or speech therapy on an intermittent basis, less than 28hrs per week or 8 hrs in a given day.
    4. Client must be homebound. Must be taxing effort to leave home with leaving of infrequent nature.
    5. Care is medically reasonable and necessary.
    6. Patient resides in a home or facility that does not perform skilled care (e.g., not in a nursing home or hospital).

    Home Health Care

    CMS (HCFA) Home Health Manual

    Have the family call the NJ Office of Aging for assistance if needed:
    Nationwide Toll-Free Telephone Number 1-877-222-3737

    Website list of all NJ office of aging agencies:

    State by state listing of Office of Aging contacts:
    Last edit by NRSKarenRN on Apr 5, '02