Big Medicare Insurers Often Deny Requests for Nursing-Home Stays

[FIREd_2015]

Article in WSJ about insurers denying access to nursing homes.

"If you’re a senior, the Medicare plan you choose may have a major impact on whether you can get nursing-home care when you need it...Medicare insurers had widely varying rejection rates for patients seeking nursing-home stays...denial rates hovered around 13% for nursing-home care...For long-term-care hospitals, initial rejection rates were as high as 80%...Appealing does appear to pay off..."

https://www.wsj.com/health/healthcare/big-medicare-insurers-often-deny-requests-for-nursing-home-stays-96817df9?st=i4qzyS&reflink=desktopwebshare_permalink

 

[jim584672]

They cover 100 days but that is it. It must be for a condition you can recover from and not a permanent condition like dementia. For that you need Medicaid.

 

[Sarah S]

This is about Medicare advantage plans. And they will get you out faster than if you had regular medicare. I know. I used to cover nursing homes especially the rehab floors. The biggest medicare advantage plan in our area ( local) had an np hired to help facilitate that ( to her credit she was excellent and would push back if it was grossly inappropriate but there was no stay an extra day to be extra ready. Regular medicare patients had the limit of days and needed to have their pt and ot documenting progress but it was kinder and gentler

 

[Irishgirlyc58]

I recently experienced this with my 96 year old mother. She is on an employer sponsored Medicare advantage program.
My mom was in the hospital for a week due to an infection in her leg and some other issues.
Due to her being inactive for a week and 96 years old the doctor wanted her to go to a SNF for 3–4 days to get physical therapy.
MA plan denied it. She went to the SNF as self pay respite care but apparently if you are self pay on respite care you can’t get the physical therapy.
Was it life threatening? I’d argue that at 96 it certainly could have been.
We had been working on getting her into an assisted living facility prior to the hospital stay. Luckily the ALF and SNF are right next door and once we got her over there she got her physical therapy.
But this was not an easy issue to navigate. I spent a lot of time going back and forth between the facilities trying to get everything in place.

I have many bad words for these insurance companies.

 

[jrendt]

Nursing home is a layman's term, like "germs". When I was a nurse case manager we never used the N word. There are several types of after hospital care facilities: Skilled Nursing Facilities (SNF), Acute Rehab, and long-term care. If you require physical therapy (PT) or some other nursing function before you can go home, you would go to a SNF. Medicare pays 100% for the first 20 days and a percentage for the next 80 days. If you require more care or if you would never be able to live at home, that is when you go to a long-term facility. This is what most people think of when you say nursing home. Medicare does NOT pay for long-term care. You are either self-pay or you are on Medicaid; this requires you to spend down you assets and after your death Medicaid will try to recover more from you estate.
When I was working, we rarely had an insurance company refuse a SNF admission if our PT department said they need it. More often it was the SNF that declined to take them for various reasons.

 

[athena53]

Medicare does NOT pay for long-term care. You are either self-pay or you are on Medicaid; this requires you to spend down you assets and after your death Medicaid will try to recover more from your estate.

I know. I see that misconception all the time.

One bit of fine print- not personal experience but a few horror stories from news sites- you must be admitted to the hospital in order to qualify for rehab paid by Medicare. Apparently it's possible to be in the hospital for several days, occupying a bed, but there "for observation".

 

[jrendt]

Until the physician write the order "admit to inpatient" you are not and inpatient. When I was working a decade ago, you had to be an inpatient for 3 midnights to qualify to go to a SNF. There was talk of changing that. Also inpatient and obs are billed differently.

 

[Lewis Clark]

Apparently it's possible to be in the hospital for several days, occupying a bed, but there "for observation".

Yes, this is certainly possible. I had never heard of this until it happened to someone I know recently.

 

[Teacher Terry]

I have read that Medicare advantage plans routinely deny rehab stays. I had the opposite problem with a friend of mine. He went to a rehab when he had regular Medicare, and we let them know when he entered that his assisted living apartment would be ready in a week and then he would be leaving as they could provide any cared that he needed. When that week was up, I notified them when we would be checking out and the Dr and I had a big argument because he did not want to see him go.

My opinion was that they wanted to run out his 20 days for the income. I didn’t want to check out against medical advice because we needed his new prescriptions since the hospital had changed many of his medications.

I finally told the doctor that I had his brother who was a Lawyer on speed dial, and would be calling him and also posting the story all over social media if he did not release him with his medication. At that point, the doctor caved and did.

It was not a good facility at all and in fact their negligence had killed my 67-year-old mother-in-law 15 years earlier when she was there for rehab and to recover from being in a coma for a month.

 

[Mark1]

I know. I see that misconception all the time.

One bit of fine print- not personal experience but a few horror stories from news sites- you must be admitted to the hospital in order to qualify for rehab paid by Medicare. Apparently it's possible to be in the hospital for several days, occupying a bed, but there "for observation".

I saw this "observation" status a few year ago with DMIL. My nephew works in the insurance industry and I remember he had a fit and made the hospital admit her she exceeded the observation limit.

I just looked up why the hospital would not want to admit someone and found the following.

primarily as a financial risk management strategy to protect themselves against insurance penalties, government audits, and revenue clawbacks.

Surprising revenue was not the reason and is actual better if the patient is admitted.

 

[gauss]

I recently experienced this with my 96 year old mother. She is on an employer sponsored Medicare advantage program.
My mom was in the hospital for a week due to an infection in her leg and some other issues.
Due to her being inactive for a week and 96 years old the doctor wanted her to go to a SNF for 3–4 days to get physical therapy.
MA plan denied it. She went to the SNF as self pay respite care but apparently if you are self pay on respite care you can’t get the physical therapy.
Was it life threatening? I’d argue that at 96 it certainly could have been.
We had been working on getting her into an assisted living facility prior to the hospital stay. Luckily the ALF and SNF are right next door and once we got her over there she got her physical therapy.
But this was not an easy issue to navigate. I spent a lot of time going back and forth between the facilities trying to get everything in place.

I have many bad words for these insurance companies.

+1
DM died at 89 yo, within a month of her employer sponsored MA plan discharging her from the hospital directly to the home.

This was in 2021 after being hospitalized for a round of COVID, With blood clot in the lungs, And now depended on high flow oxygen, and dementia

I slept on her couch for a month straight, but to no avail.


I am pretty confident I will never have an MA plan. At least while I have a DW that still wants me around.


-gauss

 

[Irishgirlyc58]

Just to clarify the issue that I posted about above. My mom was absolutely admitted into the hospital. I was there in the ER with her when the doctor specifically said I am now officially admitting you into the hospital. And then he wrote something down which I assume was the order to admit. She was there for 4-5 nights. I can’t remember now. But I think it was 5.
The only issue between my mom and being admitted into the SNF and being able to get the needed physical therapy was the MA plan- which takes over for Medicare- denying it.
The fiscal people at the SNF said that happens a lot with MA plans.