Medicare Insanity

DianaCox

Bad Cop
Looking for Medicare insurance guidance from the experts here.

Dad was in the hospital for 5 days with a UTI and the concomitant metabolic encephalopathy. At various times he has been unable to talk, walk, stand, feed himself or toilet himself, but he can do all of those things at baseline.

He was released to an acute rehab facility, with 3 hours/day of PT, OT and ST. While he was there, he had a recurrence of the UTI and regressed. It took several days to get him on more/different/IM antibiotics, and his 2 weeks are up tomorrow and the Medicare management company says he has to leave.

I have been trying to get the rehab place to get an infectious disease specialist to see him. That doctor is coming tomorrow. I think he should be kept here and the UTI treated, and continue to get intensive (3 hours/day) therapy.

I appealed the “eviction” and lost. He can only go down a level of care, to skilled nursing with some PT.

He is supposed to be getting immunotherapy every other week from the oncologist by infusion at his office. He was due last Wednesday, but he was in the rehab, so he didn’t get it last week or today.

There is a skilled nursing facility in the same complex where the hospital and the oncologist are, as well as his urologist. Great - he can get taken across the parking lot to the oncologist for his infusion, right?

Nope - the SNF gets one all-inclusive fee from Medicare for everything. If he has to get the infusions, they won’t take him, because it would cost too much. I can’t take him out and roll him across the parking lot to the oncologist, because they would have to pay for it anyway.

WTF?? Anyone have any ideas?
 

hilary1617

First time at the rodeo.
Wish I had ideas and hope you figure out something. I'm so sorry. Hope the UTI is resolved and can get back on immunotherapy and generally is feeling better soon. I can only imagine how stressful this must be for you. Hugs.
 

aaa

Well-Known Member
Is it that they won’t pay to transport him or they won’t pay for the infusion and transport?

If it’s the former are you permitted to hire an Ambulette? We used to do that for my father when he was in a nursing home and had to go to an outside Dr.
 

DianaCox

Bad Cop
If only the problem was that easy!

The SNF claims if he receives the infusion, whether at the nursing home or by me tossing him into a wheelchair and rolling him 100 yards across the parking lot to the oncologist’s office infusion room, THEY have to pay for it, and if they have to pay for it, they won’t take him on in the first place, because it “won’t be cost effective for us.” They get a fixed amount per patient, no matter how much care he needs.
 
Reactions: aaa

Spiky Bugger

Well-Known Member
Looking for Medicare insurance guidance from the experts here.

Dad was in the hospital for 5 days with a UTI and the concomitant metabolic encephalopathy. At various times he has been unable to talk, walk, stand, feed himself or toilet himself, but he can do all of those things at baseline.

He was released to an acute rehab facility, with 3 hours/day of PT, OT and ST. While he was there, he had a recurrence of the UTI and regressed. It took several days to get him on more/different/IM antibiotics, and his 2 weeks are up tomorrow and the Medicare management company says he has to leave.

I have been trying to get the rehab place to get an infectious disease specialist to see him. That doctor is coming tomorrow. I think he should be kept here and the UTI treated, and continue to get intensive (3 hours/day) therapy.

I appealed the “eviction” and lost. He can only go down a level of care, to skilled nursing with some PT.

He is supposed to be getting immunotherapy every other week from the oncologist by infusion at his office. He was due last Wednesday, but he was in the rehab, so he didn’t get it last week or today.

There is a skilled nursing facility in the same complex where the hospital and the oncologist are, as well as his urologist. Great - he can get taken across the parking lot to the oncologist for his infusion, right?

Nope - the SNF gets one all-inclusive fee from Medicare for everything. If he has to get the infusions, they won’t take him, because it would cost too much. I can’t take him out and roll him across the parking lot to the oncologist, because they would have to pay for it anyway.

WTF?? Anyone have any ideas?
Nothing worthwhile…but…a couple of random thoughts: hospitals do their best to avoid readmits within 30 days for some (financial) reason. (It sounds like he’s very close to 30 days.) Any chance the hospital discharge planner can help you acquire the help he needs…to avoid the very likely readmit to the hospital that’s in his immediate future if you can’t untangle this mess? He may have to be discharged from the rehab place and then go back to the hospital?

My Congressional Representative’s office helps me with federal SNAFUs. Medicare is federal. Call them? (Of course, the IRS screw-up they have been fixing since APRIL is due to be completed by the end of AUGUST, so that probably won’t work in time.)

This sounds just horrid. I’ve never had to deal with anything like this and do not envy you.
 
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DianaCox

Bad Cop
Probably calling my repulsive Repube rep Debbie Lesko #DebbieDoLittle on Facebook as one of my nicer comments may have been short-sighted?

Yes I think that may be a thing about the readmit within 30 days. I discussed it (among others things) with my sister this afternoon on my way home from the rehab place as something to investigate in the morning. He’s 14 days out tomorrow. Will strategize this one.

Thanks.
 

Spiky Bugger

Well-Known Member
Probably calling my repulsive Repube rep Debbie Lesko #DebbieDoLittle on Facebook as one of my nicer comments may have been short-sighted?

Yes I think that may be a thing about the readmit within 30 days. I discussed it (among others things) with my sister this afternoon on my way home from the rehab place as something to investigate in the morning. He’s 14 days out tomorrow. Will strategize this one.
214
Thanks.
Also, did you ever find/get a copy of his DD214 that you were looking for back when he lived with Sue?
<sarcasm font> In your spare time, </sarcasm font> go here https://www.phoenix.va.gov/patients/eligibility.asp or contact one of the Veterans Service officers available at the local VA Medical Facility and get him enrolled into the system ASAP. It ain't glamorous, but they have everything from primary care to long term geriatric facilities/hospice care should that be needed. I understand that this info and most of what it can get him is not as immediately available as his current needs demand, but our experience is that at the large regional centers (not the small, local clinics) they have it all—except long-term care—on one campus. And they are convinced that they can provide him with all the care he needs.


And… it’s not always “lesser” care. My now-former ophthalmologist is not in network with the Medicare Advantage PPO MrSue’s retirement board switched us to. I needed to get records transferred to a different group and that group could see me in about six weeks. In frustration, I called the VA and made an optometry appointment for a month away. But then the VA called back that Thursday, said they had a cancellation and did I want to come in the following Monday. I did. I went. The optometrist was pleased with what he saw and said he could refer me to the ophthalmologist if I wanted. My new glasses should arrive shortly. Zero money was involved. (And I can still see the local non-VA ophthalmologist. But I may put that off for a while because the VA thinks my new glasses should be good for two years and the Medicare Advantage PPO thinks the exam and glasses they pay for should last two years, so I want to alternate visits and get new glasses every year.).

AND the nice, red rollator walker I got from the VA 2622is way cooler than
your standard, red walker that Medicare covers 2623and may have a co-pay. So there’s that.
 

JackieOnLine

Moderator
Staff member
I am so sorry you are going through this, Diana, and so glad you Dad has you to do it.

I hope he gets what he needs asap, whatever that looks like.
 

DianaCox

Bad Cop
Spiky Bugger - he’s in the VA system and has been for several years. He receives an Aid & Attendance pension (or should - long story about paperwork snafu that I’m working hard to straighten out, and I now have AmVets helping me). He gets home health care from the VA too. And he does have that spiffy nice VA rollator (it is pretty easy to fold and get in and out of the car). We even have a free wheelchair from the VA, which he hasn’t used yet (it just came a few weeks ago).

As soon as it’s business hours, I’m getting on the phone.
 

DianaCox

Bad Cop
I called Medicare first. Amazingly, I got someone who knew what the answer is.


SNF Consolidated Billing
Overview on Skilled Nursing Facility (SNF) Consolidated Billing (CB):
In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. Exception: There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable.

For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

physician's professional services;
certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
certain ambulance services, including
ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
erythropoietin for certain dialysis patients;
certain chemotherapy drugs;
certain chemotherapy administration services;

radioisotope services; and
customized prosthetic devices.
For Medicare beneficiaries in a non-covered stay, only therapy services are subject to consolidated billing. All other covered SNF services for these beneficiaries can be separately billed to and paid by the Medicare contractor.

Physicians, non-physician practitioners, and suppliers should contact their Part B MAC or Durable Medical Equipment (DME) MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) Publications webpage.

Institutional providers should contact their Part A MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) Publications webpage.

He will be sent to the new place today.
 

Larra

Well-Known Member
OK, I'm late to the party as usual and you seem to have the problem solved, but I did have a thought about his current facility refusing to sent him (or let you take him) across the parking lot for his infusion because they would lose money on him. My understanding is that if a facility accepts a set fee to cover a patient's care, they can't then turn around and refuse to provide medically necessary care because they will now lose money on this patient. What if the patient's heart medication will put them over their set fee? Diabetic medication? Are they then legally permitted to withhold care? That ain't right!
So, I would think there must be some agency or other that you could complain to on your father's behalf about such a refusal. Of course, I could be wrong, but their approach to providing medical care just seems, well, not kosher.
 

Spiky Bugger

Well-Known Member
I called Medicare first. Amazingly, I got someone who knew what the answer is.


SNF Consolidated Billing
Overview on Skilled Nursing Facility (SNF) Consolidated Billing (CB):
In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. Exception: There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable.

For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

physician's professional services;
certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
certain ambulance services, including
ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
erythropoietin for certain dialysis patients;
certain chemotherapy drugs;
certain chemotherapy administration services;

radioisotope services; and
customized prosthetic devices.
For Medicare beneficiaries in a non-covered stay, only therapy services are subject to consolidated billing. All other covered SNF services for these beneficiaries can be separately billed to and paid by the Medicare contractor.

Physicians, non-physician practitioners, and suppliers should contact their Part B MAC or Durable Medical Equipment (DME) MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) Publications webpage.

Institutional providers should contact their Part A MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) Publications webpage.

He will be sent to the new place today.
Didja get him moved?
 

DianaCox

Bad Cop
Well, he was moved there late Thursday. It’s an OK place, in some ways better. He’s in a room right across from the nurses station so they can keep a direct eye on him - which is good, because apparently, SNFs are not allowed to use bed rails, bed alarms or chair alarms! WTF?? So his bed is down so low it would be hard for him to get out of bed and stand up without help.

I was still waiting to hear from both the oncologist and urologist when I had another discussion with admitting yesterday. She agreed to look into the exception. Late in the day, the urologist got back to them and he has an appointment with him on Tuesday morning, and the SNF will arrange for him to be transported there (it is literally across the parking lot, but whatever).

About 6:30 last night, the oncologist got back to me, and said he did NOT want Dad to have infusions until he is home again. I don’t agree with him, but I understand his point of view. But at least it’s not something I have to fight with the SNF about.

Dad was evaluated by PT, OT and ST yesterday (Friday) and they found him to be a little better than they expected - which he was. He was much more alert yesterday when I went to see him.

But when I went there today - wow. He's even more much better today! PT who worked with him today couldn't believe the difference since yesterday. He went to the bathroom today with little assistance. He ate his dinner entirely by himself, and asked quite normal questions like where is he, how did he get here, how long has he been here. And his speech was much clearer and coherent.

When he had to go pee, he walked to the bathroom mostly with just supervision using a walker, and then didn't wait for help when he was done - got himself up and pants up and started walking out. I got the nurse - and he decided it was time to leave. We said he could walk the hall a bit, but by the time he got out there, he just about collapsed - his strength is there, but short-lived.

I’m very encouraged.

2624
 

JackieOnLine

Moderator
Staff member
I'm so glad he is getting better! so many SNF patients really need SUPERVISION so being close to the nurses station is excellent.

SNFs are not allowed to use bed rails, bed alarms or chair alarms! WTF??
can no longer have "restraints"
 
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