My family received notice from my moms rehab / SNF that they are releasing her before they have completed the therapy as prescribed by her orthopedist . They were initially verbally telling us it was because she had plateaued and was not showing improvement . We appealed and their QIQ declined the appeal . Their stated reason is there is no longer a need for skilled nursing care and she could move to a lower level of care.
Our mother is 88 and was living independently until she had a fall and broke both ankles. The doc did surgery and put in plates and screws . He prescribed intense PT and OT , but non weight bearing . She has embraced the therapy and fully participating . Since the last visit , he added range of motion to begin working to resolve her plantar flexion in both feet . This therapy was to continue daily at least until next doc appt .
Given the docs orders and my mother’s current state, we don’t understand how any rational person can suddenly declare she no longer has a need for this therapy. Jimmo clearly says that “need” is the main criteria for continued coverage , so they have now moved away from arguing that she has plateaued and now saying she no longer needs it, so they shifted their game to hit on the correct term. But the fact remains that she very much does need it, especially now. Otherwise she will regress and be relegated to a state of total dependency. We are going to file a third appeal and trying to have doctor advocate for us with the Medicare contractor/case worker. Also, we are considering moving her to another rehab facility .
Your advice and tips in this situation would be appreciated .
8 Answers
Helpful Newest
First Oldest
First
I didn't know there were were different course options for therapy and I didn't know if you did either so I thought I'd say.
By law, medicare pays not for improvement, nor to maintain existing function but to minimalize loss of function. The law is very clear. The problem is that those first two appeals are not with medicare. They are performed by another health care company. IMO, your first real chance to win an appeal is with that third appeal. That's the first one with a ALJ or medicare employee and not by a for profit private company. The problem is after the first appeal, if you lose than you are liable for the cost of the stay. My impression is that they rely on that contingency to dissuade people from appealing.
In our case, we lost our first appeal. What I learned from that for next time was to submit everything in writing and not on the phone. I wrote out a detailed statement citing laws and policy. I didn't hear any typing while I was doing that. All that happened at the end when I stopped talking was that the rep said something like "The family disagrees with the assessment."
I got the county ombudsman involved and he had no idea what I was talking about. He stated the same "no improvement" standard. I told him that was not the standard at all and to look into it. To his credit, he did look into it and got back to me and told me I was right. Furthermore, he arranged for a lawyer to help us with the appeals for free. But by that time we had pulled grandma out of the facility. Not because we no longer wanted to appeal nor because of the cost. We were ready to go to the very last appeal. The problem was that grandma wasn't doing very well in the facility at all. I thought she was going to die there. So we brought her home. She did MUCH better at home. She's back to normal now.
That's just my experience and opinion. You have to decide how to proceed on your own. You can try to contact county officials if you have those in your area and ask for their help even if you have to educate them about medicare policy first. You could also consult a competent medicare attorney who should be well versed on how to deal with a situation like this.
ADVERTISEMENT
If she is just doing passive ROM and not allowed to weight-bear there is no reason she can’t continue at home by having PT & OT come in and give her the same exercises. Then she can go out- patient when homecare is done & she can bear weight.
Because of the rationale above, your mom will be sent home with home therapy.
So what I can offer is moral support and solidarity in this fight for our parents' health and safety, despite the attempts of the people, who are supposedly working toward health and safety, to end it all quickly.
I hope you won't mind if I watch this thread for my own benefit too. I did come here to post about just the same thing today.
Also, what is a QIQ?
Best wishes for a good outcome for you and your mother.
As suggested, maybe Mom can do home therapy. Her ortho could order it.
When you r in a rehab, your doctors are no longer in charge. The doctor associated with the facility is. Any orders going to the staff are from him. The ortho needs to go thru the facility doctor. He cannot directly give orders to the staff.
.Later, during another return home after a rehab stint, one of the OTs in the company I hired did the same thing. However, some of her suggestions weren't realistic.
That's what I'd discuss with the scripting doctor. Even after the initial adjustment of being at home, she probably would gradually feel more comfortable, especially if family members are there to visit with the therapists and learn the exercises so you can help her perform them on days when therapists come.
Good at home therapists know how to work with patients, boost their morale, and help them improve. But you do have to do some background work to check out various home therapy companies. Some aren't worth having - I had one of those and let them go after a few visits.