Help with Medicare...Should I appeal?
My mother fractured her pelvis on July 6, 2013. She spent most of the summer in rehab. (After being sent home too early from one rehab, incurring more fractures and catching C-Dif) I finally got her into a better place but once she was healed and physically rehabilitated, I was told Medicare would know longer cover her stay there. She was still on isolation and had diarrhea all day long. I could not care for her in our home so...In the meantime, I managed to move to a new home where she wouldn't have to worry about stairs any more and the bathroom has walk-in shower but was unable to move in before racking up a lot of private pay. Now I have a bill for over $6000. Can I appeal Medicare's decision successfully and where do I begin? Her doctors are very willing to help.
Since she's been released I had some home care but the physical therapist discharged her from care, so the 6 hours a week with a home health aide have been yanked and now I am trapped again. She still has C-Dif after tons of antibiotics. Symptoms are under some control with Imodium and pro-biotics but she is definitely home-bound and dependent on me for toileting. I am so frustrated because she caught this horrible bug when she was supposed to be getting better and now we are expected to pay for it too! She does not qualify for Medicaid at this time as she is blessed to have some income and assets. I welcome any insights or advice on this situation. I feel helpless and alone and am grateful for this forum.
Now about Medicaid, why won't she qualify? If this is a cash value on insurance situation, I'd suggest going ahead and getting that in line to get cashed out. This can take a bit of time and if you think that a NH is eventually in mom's future, you are going to have to do this eventually…...Use the money to pay for home health care. Yeah it's a total butt-rash to have to do this but at least you get to direct where the $ gets spent and you get to hire (& fire) the providers. Or are there other asset issues? If mom makes too much income for whatever your state has as it's Medicaid income limit, then mom can do a Miller Trust to get her income below or at whatever your state has for income max. Her income has to be one that comes from a guaranteed income source for Miller to work but it can be a godsend.
C-dif is rampant @ some facilities. Some Nh will not take a resident with it from the get go so ask about that when you look at places for mom.
About the appeal, go to the CMS site. CMS is Centers for Medicare & Medicaid. there should be a drop-down on getting information from CMS on billing & appeals.
CMS will require that you have all her info to enter the system, so go through the statements (which you should have been sent from CMS) that shows what they paid for, date and some coding or description. Now CMS may require that you fax over your DPOA & MPOA to go into detail on the appeal. So if you do not have current legal on mom to do this, you need to get this done.
perchance could mom qualify for hospice? Ask her docs about this too, Good luck and try to keep a sense of humor…...