Read Medicare for Baby Boomers and Beyond or attend a Medicare Seminar for a better understanding of Medicare’s ground rules so that you don’t become a Medicare horror story.
One of the best places to find Medicare horror stories involves Medicare’s relationship with nursing homes. You must understand that a Medicare nursing home placement is not a substitute for long-term care insurance (LTC).
There are two types of nursing home care:
Custodial Care - refers to the assistance or help with the activities of daily living (ADL) such as preparing food, bathing or showering, toiletries like combing hair, brushing teeth, shaving, and paying bills. None of these items require the services of a skilled medical professional. Medicare will not approve or pay for this type of service.Skilled Care - requires the services of skilled people such as nurses, physical therapists, speech therapists, and occupational therapists. These medical professionals perform tasks such as wound care, therapy for cardiac rehabilitation or rehab therapy after a stroke or joint replacement. Medicare will approve this type of service for a limited period of time.Rule 1:
Medicare will only approve a skilled care type of nursing home placement for a maximum of 100 days
Example 1:
Tony and his wife could not afford long-term care insurance. Tony believes that his Medicare Part A insurance will pick up the tab for their nursing home needs. Two years ago Tony’s wife was diagnosed with Alzheimer’s disease and she has deteriorated rapidly. Tony is no longer able to care for her and calls Medicare about a nursing home placement.
Question: Will Medicare approve this Skilled Nursing Facility (SNF) admission?
Answer: No. This admission is for custodial care and it is not Medicare approved.
Tony must pay out-of-pocket for this type of nursing home admission. He could appeal to Medicare for home care assistance but chances are he will also be denied for this type of service because his wife is not considered homebound.
Medicare also has the following rules for Skilled Nursing Home (SNF) admission:
Rule 1:
A patient must spend a minimum of three days in the hospital prior to admission to a SNF.
Rule 2:
The medical problem requiring SNF care must be the same problem for which the patient was admitted to the hospital.
Rule 3:
A Medicare beneficiary must be admitted to a SNF within 30 days of hospital discharge.
Example 2:
Laura was admitted to the hospital on Saturday evening, April 18th for a severe burn and was transferred to a SNF for continuing burn care on Tuesday afternoon, April 21.
Question: Why did Medicare deny this SNF admission?
Answer: Although Laura went to the hospital on Saturday evening, she was not admitted until Sunday. However, she still meets the 3-day minimum hospital requirement because she stayed in the hospital Sunday, Monday and Tuesday.
Medicare has an addendum to Rule 1:
The day of hospital admission counts toward the required three days of hospitalization prior to transfer to a SNF. The day of hospital discharge does not count toward the three-day minimum period of hospitalization prior to SNF placement.
The day of hospital admission counts toward the required three days of hospitalization prior to transfer to a SNF. The day of hospital discharge does not count toward the three-day minimum period of hospitalization prior to SNF placement.
Example 3:
Bob was admitted to the hospital on April 9 for a heart attack and was discharged four days later to his home so he could pay his taxes. On April 25 he fell off a ladder while painting the living room ceiling and sustained fractures to his wrist and leg. He was seen as an outpatient by an orthopedic surgeon who wanted to admit Bob to the hospital. Bob did not want to go to the hospital so the orthopedist decided to compromise by sending Bob to an SNF for inpatient physical therapy and rehabilitation.
Question: Will Medicare approve Bob’s SNF admission?
Answer: No. What is Bob thinking? Why is he on a ladder after sustaining a heart attack? I know that’s what you’re thinking. However, that’s not why Medicare will deny the claim. Read the following explanation for Medicare’s claim denial.
If Bob is admitted to a SNF for physical therapy and rehabilitation, he is in violation of Rule 2. He is being admitted to the SNF for a problem unrelated to his recent hospitalization (heart attack).
Example 4:
Mandy falls and fractures her hip on May 8. She is admitted to the hospital for five days and requires surgery. She decides to go home for physical therapy and rehabilitation. She seems to be responding well to home therapy and she has one of those rare PCPs who make house calls. On June 15, her PCP discovers an infection at the fracture site and wants to treat her as an inpatient at a SNF where she can receive wound care along with modified physical and occupational therapy.
Question: Will Medicare approve this SNF admission?
Answer: No. Mandy was not admitted to the SNF within the required 30 days from the time of hospital discharge.
Each month we will include additional Medicare horror stories from other segments of Medicare like those included for this month about Skilled Nursing Facilities. If you have experienced a Medicare horror story please tell me about it on our blog. Who knows? If enough of us complain about the Medicare system, we may be able to change it.
Know the Medicare Ground Rules!
Don’t become a Medicare horror story like some of the examples we presented. Before every baseball game there is a meeting at home plate between each manager and the umpires. The purpose of this meeting is to provide an explanation of the ground rules. Read Medicare for Baby Boomers and Beyond for a better understanding of the ground rules before playing the Medicare game.
Don’t become a Medicare horror story like some of the examples we presented. Before every baseball game there is a meeting at home plate between each manager and the umpires. The purpose of this meeting is to provide an explanation of the ground rules. Read Medicare for Baby Boomers and Beyond for a better understanding of the ground rules before playing the Medicare game.