When a senior or disabled patient who is on Medicare transfers to a skilled nursing facility for “rehab” after a hospitalization (of 3 days or more), a treatment plan is developed based on the physician’s orders, which incorporates all of the skilled care services which need to be provided in an inpatient facility by licensed personnel. Medicare Part A will pay for up to 100 days of such skilled inpatient care, provided that the patient meets the Medicare criteria. Once the criteria are no longer met, a termination notice is given, but the patient must act fast to appeal. As soon as you receive the notice, contact the Beneficiary Family-Centered Care Quality Improvement Organization (BFCC-QIO). They must act within 72 hours. If they affirm the termination/denial. you must contact them by noon the next day! Unbelievable, but that’s what it is. There’s a terrific packet of information and guidance provided by the non-profit Centers for Medicare Advocacy.
Restoration potential is not the sole basis to receive skilled care benefits. It’s a question of the patient’s clinical needs — the Medicare recipient must require “skilled nursing or skilled rehabilitation services, or both, on a daily basis.” This means 5 to 7 days a week, and the type of service is distinguished from custodial care which can be provided by non-licensed personnel. The old “rule of thumb” that certain conditions would only need “x” days to reach maximum improvement was never the law, as reaffirmed by CMS in the Jimmo case in 2013.
If the patient has missed the deadline to appeal, there is still the possibility of reinstating benefits. You need to ask the treating physician to prescribe ongoing skilled care if the 100 day limit isn’t exhausted and the doctor feels the patient requires that level of services. And in the meantime, therapy can be provided as “outpatient services” for the nursing home resident, there in the facility and billed to Medicare part B.
Senior care planning takes vigorous advocacy. As in most things, the squeaky wheel gets the oil, and family advocates should get familiar with these Medicare rules to helkp them navigate this complex system.
Call us for elder care planning and advocacy … 732-382-6070