“Need for skilled care” is the Medicare standard for rehab payment

We are seeing an uptick in the number of fragile elderly patients whose post-hospital subacute Medicare benefits are being prematurely terminated due to lack of improvement. Before 2013, the insurance companies that were processing the post-hospital skilled care benefits under Medicare Part A were often using a “rule of thumb” whereby they would terminate benefits if the patient wasn’t improving. Families would be told that their loved one had “plateaued and we can’t bill this stay to Medicare any more.” The Jimmo vs Sebelius class action lawsuit about this issue was then settled, and CMS issued press releases and guidelines to all Medicare insurance intermediaries, reminding them that the “improvement standard” was not the only path to Medicare reimbursement. jimmo-factsheet  The law has always been that the patient’s clinical need for skilled services is the criteria to apply.

Now it seems that the old habits are re-emerging. The Center for Medicare Advocacy was back in Court, and the federal judge who oversees the Jimmo settlement ordered CMS to carry out a Corrective Action Plan to ensure compliance with the terms of the settlement. Read about it here. Skilled care benefits can last uo to 100 days.

Vigorous advocacy is needed when your loved one enters a skilled care facility after a hospitalization of three days or more. Have a care plan meeting with the treatment team and talk with the doctor to identify and address all of the patient’s clinical and nursing needs. Read the chart and monitor the patient’s progress and needs. The patient’s physician may be the greatest ally. Keep ahead of things, because once the termination of benefits notice is issued you must file your appeal extraordinarily quickly.

Call us for advocacy concerning senior care in subacute facilities. We help you secure the benefits your loved one is entitled to. … 732-382-6070

Share This

Leave a Reply

Your email address will not be published. Required fields are marked *