Currently, father-in-law is in Rehab Center under 20%pay, Medicare pay 80%. We received notice that he goes on full pay in three days because he is not progressing. There was a legal action taken in December which the patient only had to be sustaining with the help being given in the Nursing Home.
Is this a way that Nursing Homes make money considering full pay is more than what Medicare pays?
So is FIL going to apply for Medicaid?? If so, then you want to have FIL apply to stay as "Medicaid Pending" and the daily charge will be at Medicaid rate. But if FIL cannot qualify for Medicaid, NH can bill at their private pay rate. You might want to look for another facility, if this is a true rehab place (the kind that has lots of younger trauma cases) then often the level of care is very specialized and very very expensive as compared to a more traditional NH with a "momma broke her hip" rehab room.
For Medicare rehab, the rules are very strict as to the person's "progressing" with the PT & OT having to document their treatment, weight, pain and rep's, etc and the MD's orders done. I imagine there is a formula that is used. If they aren't progressing by week 3 / day 21, you usually know they are about to be removed from Medicare paid rehab. It seems to be done every 3 weeks so they can either be accepted or declined for another 30 days.
My mom tore her rotor cuff and had surgery and did PT/OT for 4 months and the 3rd week of each 30 day cycle would be evaluated for her "progress". At 90 days Medicare would not pay anymore but the PT thought she would do well for another couple of months, so she did it and it was covered by her BCBS with the balance private pay but at whatever BCBS did not pay. That was in the contract that her responsibility was at whatever the difference was. Now BCBS negotiates prices maybe 20% less than full private fee so that was good. But PT/OT could have charged their full private pay rate otherwise. After month 4 she could roll her hair and that was her goal, so she stopped rehab. You carefully need to review the admissions contract to see what was agreed to.
You do have a copy of it and all the other admissions documents, don't you? If not, then you have to go to admission to sit & wait to get this, and yes….they can charge you a fee for providing the copies. Sometimes the documents get scanned, so they can send you the document via email for no charge. Good luck.
They do get to keep a small allowance each month - the amount depends on the state and is from $ 30 - 90 a month. Some facilities press upon family that the allowance is kept @ the NH in a resident trust account too. I don't do that with my mom's allowance but I'd say 80% of the residents @ her NH let the facility get their monthly income directly. So for us, my mom get's $ 800 from SS and 1K from retirement, monthly income 1800 and her personal allowance is 60, so each month I have to write the NH a check for $ 1,740.00 from my mom's checking account in order to be Medicaid compliant. Each month her checking account builds by 60 and I do have to be careful that her checking account never exceeds 2K as that is the Medicaid limit on assets (the NH monitors this for those that get the allowance put in their resident trust account @ the NH).
I would suggest that you have a frank talk with the PT & OT to see what FIL is doing and what their viewpoint is on the situation. It may be that FIL is just unable to do what he needs to for PT or OT or whatever rehab he is on to be worthwhile. Ditto for a talk with the medical director @ the NH. My mom was OK for surgery & rehab when she tore her rotor cuff years ago, but last June she fell & broke her hip @ the NH. Although she could have undergone surgery just fine, there is no way she could do rehab. She doesn't have the cognitive ability for PT or OT.
I bet this is why it's being declined. You know none of this is easy, nor is there really any centralized FAQ's for any of this……..not fun.
"Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly."
what I bet is going to be the hurdle is the "UNDERLYING REASONABLENESS AND NECESSITY OF THE SERVICES THEMSELVES". The question is going to be is it reasonable to continue to provide PT/OT for a NH resident who is latter stages of dementia, already cannot do their ADL's & does not have the cognitive ability to participate in their care. That is very different reasonableness than continuing to provide for PT/OT for someone with Parkinson's or early stage dementia's who is still living at home and can do their ADL's.
If the medical director & the rehab therapist do not consider the care to be "reasonable", then they are not going to write the orders and Medicare won't pay. The code word is going to change from "progressing" to "reasonableness".
If you have a family member that you are wondering about, their therapist or nurse can give you a pretty good idea how long the skilled need will last for the individual.
Medicare is usually intended for short term care. It will not cover if custodial care (bathing, feeding) is the only need.
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