NURSING HOME DISCHARGE: WHAT ARE MY RIGHTS?
The scenario: Mom, age 80, falls and fractures her hip. She needs surgery and remains in hospital for more than three days of acute care. After her hospital stay, she is discharged to a skilled nursing facility (SNF). She receives physical therapy at the SNF but, after being there for two weeks, is informed that she is being discharged because she has reached her maximum potential for rehabilitation. The family is told that Mom must either leave the facility or private pay for her stay. The family believes that Mom is not ready to go home and also believes that Mom would continue to benefit from her rehabilitation at the SNF.
In all likelihood, Mom’s stay in the hospital and the SNF is covered by Medicare. Medicare in the largest public health insurance program in the United States. Individuals can qualify for Medicare by working a requisite 40 quarters or more during their lives, or being dependent spouses of qualified workers.
Medicare Part A will pay for care at a SNF, commonly known as a nursing home, for a maximum of 100 days. If a person qualifies for the coverage, the first 20 days will be covered in full. There is a $99 a day co-payment for days 21 through 100. Many private health insurance companies will either pay or subsidize the co-pay requirement.
The problem outlined in the scenario above, however, is all too common. The 100 days of coverage that Medicare may pay is a maximum, not a minimum and not a guarantee. The personnel at the SNF make the first determination as to whether or not a patient is eligible for Medicare coverage.
The nursing home is a private facility, and like any business, they want to be paid. If they make an error and submit a bill to Medicare for someone who didn’t require skilled or rehabilitative care – the types of care for which Medicare will pay – it is the SNF that will be eating the bill. Medicare will simply refuse to pay them, and the SNF would have to try and obtain payment from a patient who has already received the benefit of the services and may not have the funds to pay, if they were willing to pay.
So, the SNF often errors on the side of being conservative. Meaning, they often de-certify patients for Medicare coverage as quickly as they think practicable, so that they are more likely to receive payment for services rendered from Medicare.
But, for all the business sense this practice may make, it doesn’t help the patient, or the family, who is now faced with the prospect of caring for herself at a time when she simply cannot. So, what are a patient’s rights when SNF personnel inform her that Medicare will no longer pay for her rehabilitation?
If the SNF does inform the patient that Medicare will no longer pay for their services, it must provide the patient with written notice of non-coverage, including information concerning the patient’s right to appeal and the procedure for making that appeal. If the patient disagrees with the SNF, the patient may request that the facility submit a bill to Medicare, even if the facility’s personnel believe that Medicare will not pay the bill. The submission of such a bill is called a “demand bill.” Demand bills must be submitted at the request of a patient. The SNF cannot bill the patient for services rendered until Medicare issues a decision on the demand bill.
A patient is not at the whim of a SNF. If you believe you are being treated unfairly by a nursing facility, contact an elder care professional. You do have rights, but you must act quickly and decisively in order to implement those rights.