Difficulties with Medicare in a Nursing Home

Posted on

Is your loved one eligible for Medicare and receiving a hard time from the nursing home? Nursing homes receive a great amount of pressure from Medicare to discontinue services that cause residents to be eligible for Medicare, and because of that, residents have to become their own advocates. Medicare payment can be very important for residents who require a high level of skilled assistance. The therapy that the nursing home provides on order from the doctor is crucial to the rehabilitation of the resident and may not be able to occur with Medicare. Residents and their loved ones should make themselves aware of their rights regarding Medicare so that they can protect themselves from these nursing home disputes.

When determining eligibility for Medicare payment, a resident can insist that the nursing home bill Medicare because the nursing home does not have the last word on whether the resident’s condition qualifies for Medicare payment. Once the nursing home has submitted this bill, they have incentive to consider with favor the resident’s needs for therapy or any other qualifying skilled service. A common limitation in most resident’s eligibility for Medicare is the required hospital stay of at least three nights. Medicare will only pay if the resident needs skilled nursing or rehab services, not just to administer medication. Before the nursing home discontinues billing Medicare, they must give the resident written notice. This may be given at the time of admission or after Medicare has paid for a certain period of time. The resident can write his own written request and insist the nursing home still bills Medicare. If Medicare will not pay, the resident can appeal, though they are responsible for bills during that time.

Sometimes residents reach a period in therapy where they seem to “plateau” or not make measurable progress. Therapy still may be appropriate at this time, though, to continue to improve the quality of the resident’s life and to keep them from getting worse. Medicare can continue to pay for therapy services even if the resident is not currently making measurable progress. Sometimes nursing homes move to prematurely end therapy because of this plateau. This decision is usually in part financial and in part medical. The resident or resident’s representative should keep in mind that recovery from an illness or injury is not always steady. Under the Nursing Home Reform Law, a nursing home resident must be provided with medically necessary care. When a resident has plateaued and the nursing home moves to end therapy because of the pressure they are receiving, the resident or their representative should force the nursing home to continue billing Medicare and convince the doctor that therapy is still necessary.

When Medicare payments have ended, therapy should still be provided whenever medically appropriate regardless of the resident’s source of payment. According to the Nursing Home Reform Law, nursing home residents should receive all services necessary to their health, regardless of the financial situation of the nursing home. If a resident is relying on Medicaid to pay for their nursing home bills, some states allow the nursing homes to be entitled to earn extra Medicaid payment for therapy services provided to residents. If the nursing home or the doctor attempts to end the therapy because of the lower payment they are receiving, the resident or their representative should explain this law to the doctor or therapist and insist that therapy is still necessary. The focus should be on the resident’s health and need for therapy rather than on the nursing home’s payments. If the doctor will not listen, you may need to switch doctors.

When a nursing home is being reimbursed for a resident’s stay with Medicare, the resident must stay in a Medicare-certified bed. Even when the Medicare program is no longer the resident’s source of payment, they can occupy a Medicare-certified bed. A nursing home may claim that they need they bed for someone else who is using Medicare, but they can simply certify another bed if they need more space. Because the Medicare program generally pays more per day than any other source of payment, nursing homes prefer to use Medicare-certified beds for residents whose care is being paid for by Medicare. Moving the resident to another bed can be detrimental to the emotions and security of the resident because they may have become comfortable already in their original room. Residents can veto a transfer if it is solely for the purpose of transferring them out of a Medicare-certified bed so that someone else can use it. If the resident wants to pursue Medicaid payment, he must be in a Medicaid-certified bed.

If you or your loved one is struggling to navigate through Medicare related problems, you need to get professional help to give you that peace of mind. The Dan Pruitt Law Firm is equipped to help you in these cases and looks forward to helping you. Call Nursing Home Neglect Lawyer Dan Pruitt today!


Dan Pruitt Logo

Get in touch with us today to get started with your FREE case review. We’re only a call, click, or short drive away.