Medicare Rant / Suggestions

[GravitySucks]

DM was in a car accident and has been in a rehab nursing center. She is getting PT and OT. I was called by the Medical Records department and told that I need to appeal Medicare deciding she doesn't need to be in skilled nursing anymore. I appealed and just heard back the appeal is denied. I started a second appeal.
Here's the real kicker. Since this was a car accident Medicare has not paid a dime. The nursing home keeps them in the billing process as a back stop since they don't know for sure when that no fault auto insurance fund will be exhausted. I'm writing a letter to add to the new appeal. Any suggestions?

 

[Sarah S]

Is this regular medicare and not medicare advantage?
Is she participating well in pt and ot and making progress?

Were you told the reasons here? Usually not progressing with pt / ot is the reason. If she is and it isn’t an advantage issue there may be documentation issues with the therapists. Usually they know what they have to write Talk to to the social worker and tey to get an idea where this is coming from

 

[MBAustin]

Second the opinion to get the facility social worker involved. Good ones can be a huge help in these situations.

 

[GravitySucks]

Thanks.

 

[Spock]

Dad got bounced from skilled nursing for not following the rules... getting out of bed with out assistance, etc. So until you find out why it was denied you don't know what issue to highlight/refute in the appeal.

 

[MarieIG]

What was the reason for the denial?

You may want medical documentation to support the fact that your mother fits the specific criteria to warrant the skilled nursing home care.

 

[jimandthom]

I have no clue how this all works, but it sounds as if the auto insurance, either hers or the no fault fund are considered by Medicare to be the primary.


You stated that the medicare system is given a bill to keep them in the loop for when the no fault run outs. I going to deny things also, until I am informed that I am now the payor.

 

[GravitySucks]

Well I wrote a letter outlining 3 Activities for Daily Living skills that Mom needs to improve with therapy before she can go home. Hope it works as the no fault auto insurance is running low.

 

[youbet]

Well I wrote a letter outlining 3 Activities for Daily Living skills that Mom needs to improve with therapy before she can go home. Hope it works as the no fault auto insurance is running low.

Did you include written backup from her doc stating the specific Activities for Daily Living she is incapable of performing? How about documentation from the NH that therapy is indeed leading to documented improvement in her performance?

 

[GravitySucks]

Did you include written backup from her doc stating the specific Activities for Daily Living she is incapable of performing? How about documentation from the NH that therapy is indeed leading to documented improvement in her performance?

Thanks. Yes I got the therapist to document improvements.
Doctors are unavailable due to the holiday but Social Workers said the medical records should show need.