Understanding private insurance that covers the gap between what Medicare pays and what a provider charges.
Expert Elder Care Guidance
Expert Elder Care Guidance
It doesn’t take much for the life of an independent person to come to a screeching halt. A fractured, hip, leg, wrist, arm, shoulder or replaced knee is all it takes to make you depend on the support of others to do everyday tasks. The problem is that Medicare has a stringent set of rules about when it will approve hospital stays and rehab – which sometimes leads to early hospital discharges and often results in additional health complications. Here’s what you need to know to ensure a safe discharge.
Medicare now has stringent criteria for hospital admissions, which has many people being discharged earlier than they are able to care for themselves at home. Complicating matters, Medicare also has a “three-day rule” requiring beneficiaries to have spent three days in a hospital before Medicare will pay for skilled nursing care. These rules are having a detrimental effect on care – and on the costs of caring for patients. “The whole point of Medicare paying for skilled care was to reduce lengths of stay in hospitals once a person has recovered but remained an inpatient because they were not strong enough to go home,” says Dr. John Messmer, a family practice physician and geriatrician in New York.
“Times have changed, and we have the ability to treat many problems in the outpatient arena that would have been hospitalizations in the past. Medicare must adapt and allow direct transfers to a skilled facility with healthcare coverage when that level of care is needed,” Messmer continues. “If that happened, we would not turn away the thousands of people who do not meet InterQual (Medicare) criteria for admission. Nor would physicians have to increase the level of intensity of treatment just to prove the admission was needed. In the long run, I think it would save money for Medicare.”
The danger of going home too soon
Consider Joanne, who believes her hospital stay was too short following her admission for a stroke. “I wasn’t ready to go home but they told me there wasn’t anything else they could do for me,” Joanne says.
Since she hadn’t met Medicare’s “three-day rule” and couldn’t afford skilled care in a facility, she went home to receive visits from homecare agencies that were covered by Medicare. But within 48 hours she lost her balance at home, fell and broke her shoulder. The break required extensive surgery. And now, besides seeing a speech therapist for her stroke, she’s in rehabilitative care for a grueling shoulder replacement recovery.
Clearly, this approach did not save Medicare money. Of course, the price Joanne is paying defies a number.
Appealing Medicare decisions and premature hospital discharge
Joanne is only one of thousands of people each year discharged too soon. So let’s look at how you can appeal a hospital's early discharge.
Appealing discharges from a skilled nursing or rehab facility
Life isn’t a picnic for those who end up in a skilled nursing facility. While many of them are anxious to get home – usually to care for an ailing spouse – they worry about money and when “Medicare is going to tell them to get out.” Nearly every day, they hear of another fallen comrade who’s been told, “You’re good to go” because the criteria set by Medicare for rehabilitation care has been met. They live in a rehab limbo of wanting to do well but not too well and fear of not doing well enough, as both will induce Medicare to shorten their rehab stay.
The good news is that Medicare also provides appeal rights for other healthcare providers that give notice that they plan to discontinue your care, including skilled nursing facilities (nursing homes), homecare agencies, comprehensive outpatient rehabilitation centers and hospice.
Once you make the appeal, following the process above, your care will be covered while the QIO is reviewing the case. This process can gain up to two days of care while the case is being reviewed. Remember: even if the QIO decides that the discharge is valid, your hospital stay will be covered during the time it took to review the case and up to noon of the day following its notification to you of their decision.
The lesson: if you believe that you or a loved one isn’t ready to leave or the discharge isn’t safe, make the call. It’s too bad so many people have to fight for their care as much as they have to fight to get well.
“As physicians, we’re taught to look out for the best interests of our patients. And now the system that was designed to help them has become a barrier to that help,” Messmer laments.
The bottom line
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