As I indicated in a recent article, my mother currently requires long-term care.  Like the vast majority of my clients, my mother was first admitted a hospital and was then discharged to a skilled nursing facility for rehabilitative care.

A skilled nursing facility is commonly known as a nursing home.  Nursing homes typically have a section of the facility that is dedicated to rehabilitative, short-term services and a section that is dedicated to long-term, custodial care services.  People who are currently in a nursing home receiving rehabilitative services don’t think of the facility as being a nursing home, but it is.

Medicare, which is a federal health insurance program available to many elderly and disabled individuals, will pay for some rehabilitative services.  Medicare will typically pay for a maximum of 100 days of rehab.  The 100 days is a maximum.  A Medicare beneficiary could receive anywhere from 0 days of rehab to 100 days, but it is guaranteed that he won’t receive more than the 100 day maximum.

Many nursing home residents who are receiving rehab in a nursing home are having that rehab paid for by the Medicare program.  After Medicare ceases to pay for their care, most of these people will leave the nursing home and will go home, if they are at all capable of leaving.  Some may never go back to the nursing home, other may be in-and-out of the hospital and the rehab center for the remainder of their lives until one day they simply cannot go home.

If a person stays in a nursing home long-term, then she must either pay for that care herself, that is, private pay, or qualify for Medicaid benefits.  Medicaid is a federal-state cooperative health insurance program for needy individuals.

My mom’s current situation has, once again, brought an issue to the forefront for me that I know a great number of my clients experience.  When a nursing home resident is receiving rehab, Medicare is paying for the rehab, and the patient’s family is probably happy because not only is that care being paid for by Medicare but the family believes that their loved one is getting better or on her way to getting better.

Those good feelings can come to an abrupt end.  The facility is obligated to inform the family when the facility believes that Medicare will no longer pay for the rehab.  The facility is not saying that Medicare will not pay for the care.  The facility is merely stating that in its opinion, it believes that Medicare will not pay for the care any longer.  The facility must give the patient or the family representative one day’s notice of when it believes Medicare will no longer pay for the rehab.

The patient has the right to appeal the facility’s decision to terminate Medicare services.  The appeal is called a “demand bill.”  In most cases, the demand bill is submitted to a Quality Improvement Organization (“QIO”), a third-party company that is contracted to handle this type of appeal.

The patient has the right to request an expedited appeal.  In many cases, the patient will be informed of a decision in a matter of days.  There is no formal hearing.  Very little “evidence” is presented to the QIO.  From what I can tell, the QIO simply takes a second look at the decision to terminate Medicare rehabilitative services and either agrees with that decision or overturns that decision.

If the QIO rules in favor of the patient, she will receive more Medicare-covered rehabilitative services, but never more than the 100 day maximum.

I have read that most demand bill appeals are successful.  In my mother’s case, hers was successful, and I obtained more Medicare-covered rehabilitative services for her.  I’d like to say it was because I’m a terrific elder law attorney (because I am … at least my mom thinks so), but the fact of the matter is, I found the entire process confusing.

One thing I can tell you is, the process happens quickly.  The nursing home is required to give you only one day’s notice, and you only have two calendar days to file the appeal.  My mother was notified Saturday afternoon and by the time I called the QIO on Monday afternoon, they were telling me I was late.  I had to jump through a few additional hoops to get things done.