Can the family doctor extend physical therapy?

The coverage amounts will vary depending on what Medicare Supplemental plan you have.

CaringSon2, they can keep the home forever or only for a limited amount of time, or is that where I've gotten the 2 yrs. confused?

I am not in the situation of a SNF or NH. But I have been down the road if Medicare Advantage denying my father to go to a In-Patient Physical Therapy Hospital. SNF and Agressive SNF are different! It was the Ortho MD whom advised my father go to the Hospital setting for PT. On that Monday after surgery I got on the phone with the Adv Medicare and told them the request to put Dad in hospital. By Wednesday I had already filed an appeal of denial on the basis they had not had a Peer to Peer review. Thursday I appealed the denial of services after the Peer to Peer. Friday Dad was sent to a horrible NH. Monday I won my appeals!

The hospital kept my Dad for three weeks and a few days at no charge to us, with a discharge to home with Home Health for weeks and then a referral to out-patient PT at the Sister Hospital that did In-patient PT.

You may have missed the original appeal right to send Mother to In-patient PT at an advanced hospital like facility.

Worse case scenario, can you move her back home and ask if Medicare will pay for In-home PT/OT/ST? OR could you take her home and have her go to Out-patient PT. I told my Dad’s that the Ortho Doctor wanted them to be agressive and High Goals! Around every six months my Dad’s doctors write new prescription for Out-patient PT to bring Dad back up in stamina and strength. He enjoys it, even with his Alzheimer’! I almost forgot that the Ear Doctor also has written scripts using the necessity of Balance Therapy.

I would suggest that you do yourself a favor and go to Ira Lef Elder Law Attorney website iralef.com to give you some insights, as he is in Georgia, and each State Administer Medicaid Laws differently. One example is that in Georgia And WV if the patient states she intends to return to the home from SNF/NH AND someone lived in the household for two years prior to admission to facility Medicaid was not able to force the sale home upon death as the person whom cared for the patient prior to admission can keep the home. But these laws change year by year.

The requirement to activate Medicare coverage of rehabilitation in a care facility is three nights after admission (and not just observation) in the hospital.

As for the question if the family doctor can order the nursing home to do physical therapy, the answer is no. The nursing home has its own doctor who already ordered physical therapy. The PT department is reporting that she is not making progress.

If your mother leaves to go to another facility or home, either the new facility's doctor or her family doctor can order PT, but insurance won't pay for it if no progress is being reported.

Not sure if anyone else said it, but being admitted to the hospital for 3 days is the minimum requirement in order for them to be able to send her to a rehab facility under Medicare. However, there are other factors that she would need to have met, such as having something that rehab could help. Once she qualifies for rehab, she does not automatically "qualify for the maximum of 100 days." Medicare will pay for a maximum of 100 days (with copays in between depending on Medicare plan) but this is not automatic. She must show progress in order to continue to be covered by Medicare. It sounds like she is not showing progress. If you feel she is, then you can appeal the decision. You are able to get her family doctor and any other records you feel show that she should continue to have therapy.

It sounds like your mother is in need of custodial care, which Medicare will NOT pay for. This must be either private pay or Medicaid.

Speak with the social worker at the facility about your concerns and intentions. If she is going to be put on Medicaid, she will likely be given therapy in a few weeks again to see if she can make any progress.

Did you appeal the decision. By law, you must be notified three days before coming off if medicare which gives you time to appeal. If they decline the appeal, appeal the appeal. If that doesn't work, then apply for long-term care. I don't think you can bring in your own community doctor, but call them to consult (to see if they agree with the nursing home doctor). It's a helpful reality check. I dislike medicare's expectations for the elderly. My mother was only allowed 18 days of rehab for a broken hip. She could only tolerate tylenol for pain management. I thought she was doing great, but apparently not good enough. To expect her to do more was abusive in my eyes. The thing is that if she can qualify for long-term care, with diligence get well enough to discharge to home. If she is low income, she may qualify for frail elder waiver or some other program that provides in home care. Meet with an ombudsman or SHINE representative or county elder services person to determine all options. I feel for you and your grandma.

As other have noted, Medicare only pays for 21 days at 100%. After that, there is a daily copay of roughly $160 for all additional days up to 100 days. That can turn into a chunk of change.

Also, as others have noted, if either (1) she is not making satisfactory progress or (2) the specific problem of admission has been adequately treated and stabilized, then Medicare will not authorize payment for additional days.

You definitely need to hold a "care conference" at the facility. However, just remember that it's Medicare that is calling the shots on this one!

I wondered if you had a sit down or over the phone Care Conference with the staff? This is set up by the social worker on staff and includes the PT, OT, ST, nursing and social worker staff. Sometimes others are there. They tell you what is your loved one's progress and their expectations. The patient can be present as well if you think that is a good idea. At my dad's rehab it was held two weeks before discharge. According to Medicare rules, if a patient is not determined that their progress will continue then they will no longer pay for therapy. However, a great article on this very website explained that if the patient has skilled nursing needs beyond PT, then the patient has the right to stay under Medicare guidelines. So if there are no needs then yes, they will discharge from rehab and the patient goes to whatever level is determined to be best suited. In my dad's case this last time he went to LTC. So my question then goes back to a care conference.

The issue will be is that her health chart at NH rehab will have therapists notes in detail as to her progress with measurements. If she is not showing progress for what Medicare requires for rehab to continue, then Medicare will stop paying their rehab benefit. It’s not subjective on the part of the OT, PT, ST but based on daily or every other day notes on her chart by the therapists. It can be appealed but if she documents “no progress”, it’s hard to fight.

So Everything was fine and then it’s not...... so did she have a fall? or a stroke? A fall can find them going from pretty good on ADLs to totally bedfast & onto hospice - it happened to my mom. Sometimes sadly there flat is no progress.  

For both my mom & MIL, once in a LTC facility, the MD with oversight on all care will be the MD who is the medical director of the LTC. The old internist or family doctor is no longer the primary physician. If there are orders or medications from old MDs, the facility will evaluate and blend in as needed. But old MDs are not determining care plan anymore. PT & or OT will still be done as a part of being in a skilled nursing facility but perhaps just twice a week. 

My mom had meds from & continued to see her old retina specialist for the first few months after she moved into NH but it was only due to a well established care plan for the type of surgery she had before moving into the NH. & I took her for the visits. But all her other old docs fell by the wayside once moved into the NH. Care is centralized through the medical director at NH. For us the only other time it changed was when mom got onto hospice as the MD of the hospice group worked in tandem with NH MD.

You mention “Medicaid will kick in”. So is mom already on Medicaid?
If not your mom is going to need to do a Medicaid application. Try asap to get the list of documentation needed from admissions or SW at the NH. There are all sorts of things needed and can seem quite overwhelming.

If mom has a home (it sounds like she was living on her own in her home) I’d suggest to have a family meeting to discuss what to do with her home IF she realistically cannot return to it. Medicaid usually allows for their home as an exempt asset for Medicaid. Although that sounds fabulous.....HOWEVER & 2 big howevers...... 1.Medicaid requires a copay or SOC (share of cost) of all her monthly income to the facility so mom will have no-none-nada of her $ anymore to pay on house realistically. All she will have for $ is her smallish monthly personal needs allowance which most states have at $50 or $60. This factoid seems to be often not clearly described to family. & 2. Medicaid is required to do an attempt to recover all costs paid on care from the estate after death. That house will become an asset of her estate. It’s referred to as MERP. There are all sorts of exemptions and exclusions to MERP but it’s totally on family to deal with whatever paperwork or legal needed to get through the Recovery process.

I've experienced this. The facility therapy staff makes the determination that someone is ready to leave, based on THEIR goals and assessment. In fact, I've seen this at least twice at the same facility. In all, I've been through perhaps a dozen rehab stints with my family. Only at the current facility and one in Ann Arbor have goals been professionally and thoroughly addressed.

While there is the issue of whether or not the person is meeting goals, there's also the issue of what the therapists set as goals. In my experience, the family is not consulted to determine if they concur with the goals, which sometimes aren't realistic. In that case my father was released well before he was ready, literally shoved out the door.

What I've also seen is that rehab facilities sometimes segue into specializations, some of younger patients with joint replacements, and in that case, the pattern shifted to quick in, quick out. Older patients with more complex issues made it more difficult for the facility to meet it's QIQO goals, and weren't treated as well. This prompted me to boycott that facility and find a better one, which I did.

I recall that at one point the facility's advertising boasted of a quick turnaround for rehab patients. Older people with more complex medical issues make that boast difficult to substantiate.

A staffer at one of the facilities in that particular consortium of facilities told me this is what's occurring now - each facility specializes in a different aspect of rehab. One focuses on pulmonary and respirator issues. Another focuses on joint replacements. There's nothing inherently wrong with this other than that "specialty" should be explained to family and patients before the facility is selected.

Some years ago, we experienced the opposite situation; the rehab facility tried to extend my mother's stay past her recovery point, even though her ortho doctor felt she was ready to go home.



What were the specific reasons for your mother's rehab? Was it overall general health, and if so, were the facility's goals ever explained to you?

Based on your description of your mother's status though, it does sound as though it's appropriate to consider a higher level of care. We've been through that; sometimes it's like a minefield as many of the agencies I contacted and vetted just didn't meet standards.



MichiganGirl, I too live in Michigan, and this is where I've seen this specialty trend in rehab. If you want to share the specific name of the facility, PM me. I might have some more info to share, if it's one of the ones we've used.

The question really hinges on whether she is continuing to make progress in therapy.

I think you may be confused about what Medicare covers. They will cover 20 days of rehab at 100%. From day 21 to day 100, your mother must pay a co-host of about $160. Is that what she's being asked to pay?

If she has a Medicare supplement, that should kick in and pick up the cost.