Navigating the care of a loved one in a skilled nursing facility can seem very daunting for family members and friends entrusted with the role of advocate. Justice in Aging compiled a handbook called “20 Common Nursing Home Problems—and How to Resolve Them.” So far, we have outlined 10 of the 20 problems identified in this piece. Problems number 11 through 15 address the sometimes complex issue of Medicare payments.
#11 Refusal to Bill Medicare. Simply put, it is not up to the nursing home staff to determine if a patient is entitled to Medicare payments. A resident, or resident-advocate, can insist that the nursing home submit a bill to the Medicare program for therapy or any other qualifying skilled service. It is important to keep in mind that Medicare payment is often dependent on a tie to hospital care. If a patient was formally admitted and had a hospital stay of at least three nights, and then enters a nursing home within 30 days of that hospital stay, they are eligible for a Medicare payment. Payment in full is only made during the first 20 days of a nursing home stay. Days 21 to 100, should they be necessary, require a daily co-payment. This co-payment can be covered by a Medicare Supplement insurance policy. A new benefit period begins when a patient has not used a Medicare payment for a hospital or nursing home for at least 60 days. The resident and their trusted advocates need to compel the nursing home to submit a bill to Medicare and also convince the doctor or therapist to continue ordering appropriate services.
#12 Losing Therapy for Supposed Failure to Make Progress. Medicare could be placing some pressure on the nursing home staff to terminate therapy. Therapy may still be an appropriate intervention even when a resident is not making measurable progress. Therapy should be provided if it improves the resident’s condition, maintains the resident’s condition, or slows the decline of the resident’s condition. A common term used in the nursing home is that a patient has “plateaued” and is no longer making progress. Every resident is entitled to the same high quality of care, regardless of the payment source. Federal regulation states that a restoration potential or standard of “improvement” of a patient is not the deciding factor in determining whether skilled services are needed.
#13 Losing Therapy After Medicare Payment Has Ended. Therapy should be provided whenever medically appropriate, regardless of the payment source. Therapy services are required under federal guidelines to be provided even if the nursing home is entitled to no more than the typical Medicaid rate. It is vital to communicate with the doctor overseeing care and to convey that the focus needs to remain on the resident’s need for therapy and not on the finances of the nursing home.
#14 Forced transfer within Nursing Home after Medicare Payment Ends. Nursing homes seek certification for all or some of their beds through Medicare. In order for Medicare to be billed for care provided to a resident assigned to the bed, the bed must be Medicare-certified. A Medicare-certified bed can be occupied by a resident who is paying privately or through the Medicaid program—as long as the bed is also certified for Medicaid payment. Medicare generally pays more per day to the nursing home so many nursing homes prefer to use Medicare-certified beds only for those whose care is being reimbursed by Medicare. Hence, sometimes nursing homes look to move a resident out of their bed when they are no longer eligible for Medicare payment. While this move may be motivated by financial reasons for the nursing home, it may be a difficult move for the resident who has grown accustomed to their space. A resident does in fact have a right to veto a transfer if the purpose of the transfer is to move the resident out of a bed at that is Medicare-certified. A nursing home is always free to seek Medicare certification of additional beds if necessary.
#15 Refusal to Accept Medicaid. In many situations, residents initially pay for services privately, but later become eligible for Medicaid payment after spending down. If for some reason a nursing home has not certified all of their beds for Medicaid, it has the option of certifying additional beds for Medicaid payment. Prior to admission, a resident or a resident’s family should be aware of the nursing home’s Medicaid certification status. If after admission a resident needs to ensure that their bed is Medicaid certified, it is ideal to inform the nursing home administration that this will be necessary about four to six months before becoming financially eligible for Medicaid.
At Weatherby & Associates, PC, we appreciate the complexities of the ongoing job of caregiving when a loved one is in a skilled nursing facility. If you have any questions about advocating for your loved one, contact us at 860-769-6938.