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Life Health > Long-Term Care Planning

Nursing home claims DENIED!

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In our business,our team lives on the road.

When we aren’t talking about caregiving, we are listening to family caregivers and we hear a lot of personal stories. Many of the stories fall into little buckets or genres that we’ve often heard before.

Recently, we have noticed a new story. This story, unfortunately, will become a recurring theme if we don’t fix the underlying problem. It’s the age-old problem of unintended consequences with no place to point the finger.

Hospitals are using “observation units” when people come into the ER for something and they feel the patient needs to be watched for a period of time.

This care is in the hospital but a less intense level of care and, therefore, less expensive care than “inpatient care”. You might stay several days in “observation status” and since it’s not “inpatient care” those days help save costs for all involved. Sounds like a great solution right?

However, in order to pay for skilled nursing services under Medicare when a person cannot return to their or a family member’s home, Medicare requires a three-day “inpatient” hospital stay.

There’s the catch! Inpatient stay, not observation unit stay. If one of us stays three days in the hospital and then needs to go to a nursing home our natural thought process would think, “Ok, fine, I was in the hospital three days, so Medicare picks up the first couple of weeks in a rehab unit or nursing home.”

BUZZ! Wrong answer. How do we explain that to the general public? In order for Medicare to pick up the tab for those first couple of weeks nursing home care, we have to fight the hospital to give us inpatient status when that level of care may not have been needed.

What has to change? We don’t want hospitals to use a more expensive level of care than needed, but we don’t want family after family to fall through this hole in the safety net!

This means we have to lobby Medicare to change their rules and technically “expand” Medicare coverage – not an easy or quick task.

But is it really expanding? I would argue that it’s simply repairing a hole that popped up because someone came up with a new kind of hospital care classification. In this time of fiscal cuts I doubt my argument will be seen that way; it will be seen as Medicare expansion.

If you have any clients or family members potentially dealing with hospital stays followed by nursing home or rehab stays, please let them know about this hole in the safety net!

I don’t have any perfect solutions, but bringing the problem to light is the first step they tell me.

For more on this issue, here’s AARP’s recent bulletin on the topic. 

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