medicare policy in LTC

Blackcat99 · Jun 21, 2006

I would think that it would be the admitting person from the billing dept. Isn't it wonderful to find out this information after the fact?:angryfire Billing should have told the daughter about this rule on the day of admission. It's certainly not a nurse's fault for not knowing this billing policy.

Midwest4me · Jun 21, 2006

I would think that it would be the admitting person from the billing dept. Isn't it wonderful to find out this information after the fact?:angryfire Billing should have told the daughter about this rule on the day of admission. It's certainly not a nurse's fault for not knowing this billing policy.

I agree with Blackcat99---that is a FINANCIAL issue and not in the realm of the nurse's expertise; therefore not the nurse's responsibility.

catlady, BSN, RN · Jun 21, 2006

I never knew that a patient who was on medicare could not go out of facility overnight. Out of 39 patients I had one pt. I never saw a policy or procedure on this account. Never worked anywhere else. Here is the situation:
The other night pt dtr came and picked her up. I gathered her meds,etc. Did the documentation. Done deal. Yesterday, management didn't have the guts to tell me, but dayshift nurse told me that pt is off medicare because she went home overnight. So when the dtr returned last night, I told her what happened. I took responsability for not knowing the policy.(even through the policy is not on the unit or anywhere else for that matter) The daughter told me that she did not even know that her mother was on medicare. She thought she was on title 19. Who's job is it to tell family members what status there payment, etc. in this type of situation.

Someone *really* needs to understand Medicare in your facility, and it doesn't sound like anyone does. The fact that the resident went home overnight doesn't automatically mean she's off Medicare. It does affect the PPS calendar, and there needs to be a documented reason why she was allowed an overnight pass, but by itself it's not a reason to kick someone off Medicare. And if someone is dropped from a Medicare A stay, the resident and family are required by law to receive official written notification, and to be advised of their right to appeal the decision. Someone in your building--whoever manages PPS from a nursing standpoint, probably the MDS coordinator--should have been monitoring the Medicare residents and should have known that the LOA was planned. I have told families that they could not take their loved ones for overnight visits or even non-therapeutic afternoon visits while they were on Medicare. (I tried to be reasonably lenient in the interpretation of non-therapeutic, but I wouldn't accede to Medicare fraud.) If the family insists, then they are told right then and there about the consequences as far as Medicare coverage.

Sometimes the family is not aware they are on a Medicare stay, especially if it's a long-term resident who's now on a short-term Medicare A stay because of a hospitalization. Once the Medicare exhausts or they go back to unskilled, they go back on Medicaid or whatever their primary payor source was. Unless they were private pay, the family doesn't even notice the difference.

Never would I have expected the floor nurse to know about this or to discuss it with the family. However, for future reference and to make your life easier, you should always alert someone in management if you have a resident planning an overnight. It affects billing, whether or not they are on Medicare.

HisHands, ASN, RN · Jun 21, 2006

I was under the impression that medicare patients had a certain number of hours they could be outside the facility per year. We had a similar situation, and actually had to tell the daughter that she couldn't take her mom out because she was too close to her allotted hours for the year already in February.

I didn't know they could actually remove medicare benefits for one night out. That seems truly stupid to me.

Nascar nurse, ASN, RN · Jun 22, 2006

I was under the impression that medicare patients had a certain number of hours they could be outside the facility per year. We had a similar situation, and actually had to tell the daughter that she couldn't take her mom out because she was too close to her allotted hours for the year already in February.
I didn't know they could actually remove medicare benefits for one night out. That seems truly stupid to me.

From a medicare stand point tho, they are paying for someone who is "acutely" ill (acute by LTC standards - not hospital) and require DAILY skilled nursing care. From a medicare point of view, if you are well enough to spend the night at home, then you are also well enough not need need DAILY skilled nursing care and therefore you are no longer covered. Make more sense?

I have never heard of anyone having a set number of hours allowed out of the facility. It's either a therapuetic leave or its not. We RARELY allow anyone out overnight - the 1% of the time this happens is when they are out for a sleep study or something of that nature.

fuzzball · Jun 22, 2006

Greetings

Update on this medicare situation. Guess what? It is a billing situation. I was told tonight on pms that the pt is back on medicare. They cannot bill medicare for the one day she was out. Strange indeed. Anyhow the dtr still was not informed of this. I discussed the situation with her and she trotted off to billing. She had to investigate on her on-of course I told her to. It is her right to know. I do not know why this nursing home does this sort of thing. It disturbs me deeply. Also it was mentioned they lost hundreds of dollars-hinting to me. Of course I was told it was nobodys fault. I think it was management for not letting patients daughter know. The daughter stated she would have never taken her out. THe daughter by the way called me a 1800 and management was long gone. She was out of building within 10 minutes for a unexpected funeral and to see long ago relatives. That was the scenerio. I thank all of you for your great knowledge as usual. Thanks for reponding!

CoffeeRTC, BSN, RN · Jun 22, 2006

If the pt is on medicare and leaves the facility (LOA or ER visit) and is not back in the facility by 12 midnight, then medicare can not be billed for the day. That doesn't mean that theyare removed from medicare all together.

As far as the situation...I would think that when they went to medicare (either at admit or a readmit p a qualifing stay) the SW or billing departmetn would have explained this either verbally or in writing.

CapeCodMermaid, RN · Jun 22, 2006

I don't know about where all y'all work, but at my facility there are piles of papers with endless things families are told. NO ONE would be able to remember it all. A patient on the Med A benefit is not allowed on an over night...Medicare won't pay for the day and if they are well enough to go out overnight, they don't have a skilled need.

And I must disagree with some posters...this is the year 2006. Nurses need to have a clue about the financial end of the business. Ask your PPS nurse or business office to have some inservices on Medicare regs.

And...hmmm...if the patient had gone to the hospital and had re-accessed her Medicare benefit, the family should have been told.

ktwlpn, LPN · Jun 22, 2006

if you work in a private facility with a limited number of medicare certified beds no one ever seems to know what's going on.add in your hmo's ppo's and various plans and it's a nightmare..i work in a county home and all 200+ beds are certified..i know that medicaid folks have a certain number of nights a year they can take loa and not loose their benefits.our social workers and rnac staff keep track and notify the residents and their families....i've never come across this problem with a med a resident but i'm sure it has probably happened at sometime.....shame i'm on loa myself--- :lol2: i'll have to find out the answer sometime in the fall when i go back to work.....but it makes sense to me-med a is skilled so an loa seems unreasonabe at that time. some inservice time is a good idea...our rnac staff post a list on every unit of the current medicare a residents and their dx...this has been invaluable because we have alot of agency staff and float staff......we also have rules regarding loa-we must have 48 hours notice because we have to order the meds from our pharmacy-we are not permitted to pull them from the resident's stock ....we never have families just running in to pick up mom or dad for an overnite...don't beat yourself up over it---the blame here can be spread,i think.....