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My late 90 year old wife, who was confined to an Alzheimer's Ward for two years, and was given 59 of Self Care/Home Management sessions over the first six months of her stay. Medicare Summary Notices reported payments of $1443.00 to the nursing home.and our co-payments were $360.00. The co-payments were waived after I complained. Half way through the six month period, my wife fell and broke her shoulder becoming immobile and unable to participate. However, Medicare was continually billed for over 515 Physical Therapy sessions totaling $12,500.00 through this same period. Although Medicare yearly limits for this therapy were $1840.00, the nursing home was claiming these treatments were medically necessary. Can anyone explain how that could be?

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My answer is here when you asked something similar the other day. https://www.agingcare.com/questions/criminal-or-civil-offense-nursing-home-to-commit-medicare-fraud-177084.htm
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I have no idea but, I attended numerous therapy sessions with my mom as an inpatient at a rehab facility when she broke her wrist. They were a joke. They were group therapy sessions. She would have benefited much better on a one to one therapy session and I chose to do it in her room myself. After a week no one had encouraged her to walk, she was kept in a wheelchair the whole time. After complaining i was able to get a therapist to help me as I got mom up and walking again with a walker. I was not permitted to walk her alone. By the 3rd week, I made sure I had one of my kids with me to help push wheelchair behind her because I could only get the staff to help 2x per day. I was very disheartened with the whole experience. Out patient at home therapy was much more beneficial. Good luck getting answers. I am so sorry on the loss of your wife.
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there are a lot of actions Pureshooter can take. Depends on how you want to go with it. For example, you could file an online report with Medicare's Fraud Unit at http://www.medicarefraudcenter.org/nursing-home-fraud.html. Or you could ask to sit down with the facility's administrator and ask him/her to explain the billing better. You could ask to talk to the PT or OT that was providing the services and see what they thought they were doing. You could ask for a copy of the treatment notes, read them and then meet with the care providers. There may be a long term care ombudsman who can help you with this as well, depending on your state. If it were me, I'd report this bunch to Medicare for potential fraud. But on the other side of the coin, a broken shoulder does not mean that a person cannot participate in therapy; in fact it means just the opposite..they should be participating in therapy.
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Medicare generally will not pay for a rehab stay if there is not a degree of continuous improvement via therapy. This is sort of a catch 22 as you may be on the hook for her stay even though she broke the shoulder while under their care. Tread lightly and get all your ducks in a row before you claim any fraud. If they are offering therapy in other areas and she is improving otherwise, I would let it go and investigate any liability they may have for the broken shoulder. Again, tread lightly.
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Can I ask you was she in an acute care rehab facility or a NH masquerading as a rehab facility? I have been in an acute care facility and i had 2 hours of therapy ( each in speech, OT and PT) I have MS, that right there was 6 hours a day, six days a week, some acute care facilities are aggressive when it comes to therapy.. just curious. The ones i have seen who bill themselves as rehab centers but are not, generally give you 1 hr os therapy a day 3 or so times a week... check to see what she is being treated in...
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With a doctor's order. He can write it as part of her plan of care. Ask him if you can implement it for her or if it has to be a licensed P.T. He will tell you what to do next. blou
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I'm sorry. You are seeking reimbursement for your payments & to Medicare? Is that right? Do you know if they continued to see her when she was immobile? They may have changed her care plan & did something, still. There are records of this. You have a right to ask for them whenever you want. Go to the billing dept atr the facility where the the therapy was provided. Tell them you want all of her medical records including invoices of what was paid & by whom for what services so you can settle her affairs. They have to provide you with this. Take care & good luck to you. I am very sorry for your loss. blou
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I don't know why a facility which receives Medicare PT/OT reimbursements, would ever over-bill, which is what 515 treatments over six months sounds like. ddon't think you need to report it as fraud, instead just ask for an itemized bill for all 515 treatments, and also get a copy of her med rec, and go thru and find the documentation of all 515. There has to be some error here. Are you private pay, after Medicare? That might be why. If there were insurance, I'm certain the insurance would be scratching their heads over this too.
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