My mother in law is in a nursing rehab center for a broken ankle and hip but insurance is refusing to pay. Any advice?

im an idiot and ive always despised the insurance industry but i read a lot and recently ive learned that the insurance industry ( govt agents ) are at least to be appreciated for checking fraud in the health care industry . there is no 100 . 00 aspirin anymore . my son split his head in a single auto accident a few years ago and was issued dollar store aspirin directly from the local hospital . seems the dollar store had the most competitive price for the med .
i still hate health insurers but under yobamas directives they will spend 80 cents per dollar on services . many insurers are not expected to survive .

My mom had a mini stoke with a fracture knee and was in rehab. She was in the hospital and then sent to rehab, Yesterday they inform me that she will be discharged on Monday. I appeal it on Friday and the insurance called on Saturday and denied her. She has Medicare and Well Care. She need at least another month to heal with no weight on her left leg. She is 93 years old I don't understand these insurance companies. I will search for other option but giving up on my mom is not one of them. Shame on these insurance companies!!!!!

Also, are her therapists supporting the Medicare appeal? When my mom was denied a continuation of therapy, the therapists and the facility did the appealing, family had nothing to do with it.

Jenny, people don't go to nursing homes to die. My mom, post stroke, post hip surgery, is in a NH. Got therapy to get her walking again. It stopped being paid for by Medicare when she stopped progressing. But each time she went to the hospital for three days ( a fall, pneumonia), it would be covered by Medicare again until she stopped making progress. Mom has gotten much stronger physically since going there.

An elder really has to be willing to accommodate a bit to the therapy schedule, it's sort of like going to school. Are there other reasons why she's so tired? Is this an acute rehab facility ? Maybe she needs a subacute facility .

The five hours of PT is not all strenuous stuff. It's getting out of bed. Going down to work with a physical therapist, staying up for brain exercises, some arm work, more brain exercises. They basically want her up and doing something for five hours straight. The worst part is that her normal schedule is off. She always slept in late in the mornings and went to bed at like 3am. She's always been like that. She likes to read until late at night and will sleep in until noon. They have thrown her off her schedule to fit in with their own so that's another reason why she's so tired all the time. I'm just feeling stuck and I cannot put my grandmother in one of the those homes to die. If I had the money I would pay for her to stay in the best place possible but I don't, my mom doesn't and my grandmother has no money. She's on Social Security. She has great insurance but that doesn't mean crap if Medicare is not paying a dime.

The problem is that when she first got there she didn't participate as much with PT because her meds were off. My mother finally insisted on them cutting out certain medications and it took a couple weeks for the meds to wear off and she is now reading the entire newspaper daily and attempts to walk to the bathroom by herself as long as someone is near by. She lived alone before this all happened but she cannot go back to living alone unless she gets back to where she was physically. We filed the second appeal with a letter explaining the medical care at the hospital was to blame for her lack of participation. She likes where she is and she enjoys the therapists there. She participates now but every once in awhile she has a bad day where she's just exhausted. We've seen great improvement and I hate the fact that Medicare can just deny a claim without even seeing the person, just a few notes on a file saying she didn't participate today. It's so upsetting. If she goes into a nursing home that has a medicare "bed" available she'll just be going there to die. She's completely healthy. Her doctors say that all of her organs are that of a 60 year old. She's very intelligent. She repeats herself but she did that before this all happened. She's up to date on current events. She just needs time and therapy to strengthen her legs so she can get up and move. She can't do in home PT because she cannot live alone and we don't have a room to put her in. We would take her if we had the space and I didn't work but I cannot leave her alone. I'm just wondering if anyone had any experience winning appeals with Medicare. Any tricks you used? letters from doctors? family members?

While learning the ins and outs of rehab, we too learned that Medicare will not pay if a patient is not cooperating and/or not progressing. However, given that meds were affecting your MIL's ability to participate, I would think that should be a factor in considering that initially she couldn't participate. You write that she is active in PT now - was that raised in the Medicare appeal?

There is a second level of appeal generally in Medicare denials of payment. I went that route in challenging meds directly billed by a hospital. Medicare took several months to deny the first appeal; I challenged and went to the second level. Medicare never did respond and the hospital just dropped the charge. It pays to be aggressive.

There are some attorneys who handle challenging Medicare, but you'll pay from $250 to $300 an hour, and there's no guarantee they'll win. There are also ombudsperson agencies that offer advice, but generally it's on rehab/facility issues. It wouldn't hurt to do some quick research and see if you can find some of these types of agencies in your state.

We also learned that some rehab facilities require "intense" participation, which some years ago was considered 3 hours of PT/OT daily. I've never heard of 5 hours of PT. You've have to be an Olympian to recover from surgery and do that much PT.

I would ask the social worker about the issue of "5 hours of PT daily" and see if that affects everyone in the facility. The ideal solution would be to find another facility that doesn't require such high levels of participation, but you'd have to do that quickly and it sounds as though there's not much available in your area.

I did find, however, that direct calling got me farther than relying on any discharge planner or social workers. In fact, I don't recall that of any of the facilities I called, there weren't any vacancies that would have arisen in a few days.

Sometimes it's worth it to go out of area though. When my father needed special rehab for ventilator weaning, I eventually found a facility which was 30 miles from where I was living then. It was a long drive, but well worth it. It was absolutely, hands down, the best rehab facility I've ever seen.

I agree also with Babalou that you could ask her doctor for home PT (and nursing and OT), which would allow progress at a more realistic pace, and in the comfort and familiarity of her own home.

Who is telling you that they expect her do five straight hours of PT?

If she's not making progreas (based on the report of her theraposts), she no longer qualifies for inpatient PT. Will her doctor acript in home pt, which would be less taxing?

My 86 year old grandmother was placed in a rehab facility after she was in the hospital for a couple weeks stuck in bed. The hospital screwed her medications up which practically put her in a semi-comatose state. At the rehab center they finally got her medications right and she started participating more and more in the PT and social events. We just got a letter from Medicare that they will no longer pay for her to stay there due to her lack of participation. We filed an appeal and it was denied. So we filed again in writing and we are waiting for an answer but as of tomorrow Medicare is not paying for her rehab stay. Has anyone experienced this? My grandmother is 86. Before she was hospitalized she didn't walk around that much because she has a bad back and she's old! Medicare is expecting her to get up and do five hours straight of PT which is a lot for her. Some days she does it, other days she just exhausted and can't participate for the entire session. We can leave her at the rehab center but they are going to bill her $350/day. We've looked at long term places but they are awful and I wouldn't send my dog to these places. The nicer places have six month waiting lists. What can we do to keep her in this place? The rehab thinks she should stay but they have to get paid by Medicare so they are stuck as well.

Social worker.

Talk to the dovial worker at the favility about when a "care plan " meeting is schedled. You will meet with her therapists and a plan will be developed with you . Think about whether she will be able to manage at home, post rehab.

my mom has alzheimers and had a stroke recently. She was kept as inpatient in hospital for 8 days and transferred to subacute rehab. Hers was a "small" stroke. Haven't been told how long she'll be able to stay. I have no longterm plans in place. Overwhelmed

My 86 y.o. mom broke her hip on Mother's Day and is in a nursing home/rehabilitation facility. She is considered "short term" during PT and Medicare pays 20 days, after the 21st day Medicare pays 80% and her Blue Cross picks up the other 20% til the 100th day. While in short term, Medicare requires progress updates, and only if she is not progressively doing better with her therapy will Medicare reevaluate her for possibly discharge from short term and stop paying. I already filled out "long term" Medicaid paperwork so that in the event she is discharged from short term to long term care, Medicaid will be in place, (hopefully). Also, after the 100 days, my mom will probably transition into long term anyway, therefore, Medicaid will have to be in place to start payment.
I also had certain rehab facilities refuse to take my mother, but it was based on a facility that had a more rigorous physical therapy requirement, like 3-5 hours a day. Since my mom is 86 and has dementia, there's no way she could have withstood that amount of PT. BUT, these rehab places would not have kept her but 2-3 weeks at most, not 100 days. A nursing home with rehabilitation is what you need. Just make sure you go and check the places out prior to transferring her there, and it's a good idea to make sure the "short term" patients are separate from the "long term" patients.

I agree that this does not make sense . The rehab places that evaluated her said that there afraid she will run over the 100 days and then she would be Medicaid pending to pay for her care . They don't want to risk it because once she is there they can't make her leave. They are assuming the worst case . It's seems it's all about the mighty dollar . There should be some kind of law to protect people from this. My mom needs to be in rehab to get stronger and learn how to transfer from lift chair to a commode because she is a heavy women and me or my dad can't lift her

Huh? She has insurance that will pay for 100 days and the rehab place won't take her? Many rehab facilities (TCU) are within nursing homes. Does the facility think she is applying to live in the nursing home? This is very confusing.

Reenie, that does not make sense! Having 100 days sounds like Medicare and why would she be "Medicaid pending" if she has Medicare? Is there a lot more going on besides the borken ankle, such that they do not think she will be able to accomplish any rehab goals? I'm not aware of many facilites that don't take Medicare...Do you have any options to have therapy for her at home? Where is she right now?

My 84 year old mother broke her ankle and can't be on for 2 months. She needs rehab to learn to transfer with her good leg. No rehab will take her and she does have insurance that will cover 100 days. They say she would be Medicaid pending. Is there anything I can do.

Thank you so much for your response on this! They actually did say that she could put in an appeal and in a round about way said it will probably not get approved. We will definitely try this route along with applying for Long Term Care and see what results come out of it.

You can probably appeal the denial on the grounds that she stil qualifies for PT for strengthening her legs/preventing loss of muscle strength and mobility, enable safe transfers, etc. She rpobably meets rehab criteria as long as there are functional goals for both PT and OT that can be acheived despite not weightbearing on the legs initially. They don't necessarily TELL you can appeal, let alone how. Admissions coordinators at the facility should help you with this process. Plesae let us know how it turns out! I suppose the alternative is to arrange a lot of in-home therapy serivces, and some insurers don't cover that very well either. Do your best not to let them get away with unreasonable denial of service. It really should not be this hard!