How the System Seems Stacked Against the Patient.

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I wish I had a crystal ball.  If I had one, I would have known that dad would only be in the hospital for 4 days. When dad was rushed to the hospital on last Monday with internal bleeding, he had lost about 25% of his blood volume in one day.  When I arrived at the emergency room, he was almost completely unresponsive and pasty white.  All I was able to get out of him was a response to Dad, it’s Barbara.  I am here.  Can you hear me?  He responded “yes.”

I thought this was it.  The doctor said he was in a life-threatening state and that I should call family. Again, the questions were thrown at me.  “Do you want us to resuscitate him?  Put in a breathing tube?”  It all happened very fast and it was frightening.  I was doing this all alone.  The rest of my family is up in New England and my kids are both living out of the State.  It is during these times that the words “Stay Strong” have the clearest meaning.

Later that day, I got a phone call from the skilled nursing home dad had been at for 10 days receiving rehab.  He had made really good progress there and both my husband and I felt really comfortable with the care and attention he was getting.  The place was also very well maintained and on a stunning piece of land so there were peaceful places to take dad outside on a beautiful day.  The facility called me to tell me that because dad had been brought to the hospital, Medicare would stop paying for his bed at the skilled nursing facility within 24 hours.  If I wanted to, I could private pay for that bed to hold it.  The cost would be $325/day.

I thought about it for a millisecond and responded “no thank you.”  I didn’t know what was happening to my dad at that time, how long he’d be in the hospital AND he was already paying $4500/mo to “hold” his spot at the assisted living place he had been living before his hip surgery.  So I couldn’t see paying for THREE places at once – the hospital, the assisted living apartment AND the skilled nursing bed?  So I said, ” no thanks.”

What I should have done is slowed myself down.  The skilled nursing facility certainly wasn’t pressuring me to make a snap decision.  They said I could take a few hours to get back to them and think about it.  That’s what I should have done.  Buying a little bit of time would have given me more time to get a handle on exactly what was going on with my dad, what the hospital planned to do about it and would have given me a better gauge as to how long he might be there.

Fast forward to his discharge date and, of course, the place he had been receiving rehab no longer had a bed available and so my poor dad had to go to yet another rehab facility.  This one isn’t nearly as nice a place, although I think the rehab seems to be just as top notch. And at the end of the day, that is the most important thing he needed.

For most people, a different rehab facility isn’t a big deal.  For those dealing with dementia, as my dad is, it can be extremely stressful.  He now has to get used to all new surroundings (again), new people (again) and essentially restart his therapy from the beginning (again).  Not easy for any elderly person, but for those with dementia, it is very very difficult.  Again, the system seems stacked against the patient, rather than working for the patient.

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I’ve told you about the 60-day rule. There is also a 30-day rule. Who knew?

30days

I tell you – I learn something every day on this job.  Today’s lesson is about Medicare’s 30-day rule. I tell you this so you don’t have to endure the additional stress I did when my father was rushed to the hospital from his skilled nursing facility when he started to bleed internally. I was not only worried about my father but also whether he had just screwed up the 100 days of skilled nursing eligibility with Medicare he had qualified for with this recent hip surgery.

The typical eligibility rules state that you must be “out of the system” (meaning healthy) for 60 consecutive days in order for an incident to re-set the clock making a patient eligible for another 100 days of skilled nursing care.  My father had been healthy for 61 days.

He was getting skilled care when he started bleeding internally and was rushed back to the hospital after only 10 days of skilled care.  Normally, in order to be Medicare eligible for skilled services, a patient has to be in the hospital for 3 days (admitted, not just under observation) before you are eligible for Medicare.  I was stressed because I didn’t know whether he would be there for 3 days and if he wasn’t, I was worried that he wouldn’t be eligible for skilled services after he was released because he went back into the hospital. And he certainly wasn’t walking yet.

HERE’S HOW IT WORKS

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay. BUT….if you go back into the hospital within that 30 days period, the skilled care just continues on from where you left off – no need for a new hospital stay. Knowing that would have relieved that element of stress I was experiencing.

As it turned out, my dad was in the hospital for 3 nights, 2 of which were in the ICU.  He had lost 25% of his blood in one day from an ulcer in his small intestine that had been aggravated by the blood thinners which are routinely given after hip surgery (to prevent blood clots from forming).

Happy to say, he is out of the hospital and back into rehab.  My only disappointment was that I was not able to send him back to the same skilled nursing facility he had been at, which, in my opinion, was top notch.  In my next blog post, I will talk about what I wish I had done and could have done to avoid having to move him to yet another new environment….if I only had a crystal ball.

Please share this important information with your friends and family.  You never know when you will need it.  It is good info to file away in the back of your mind.  Because someday, we will all have the privilege of growing old.

The Medicare 60-day rule. Critical to know.

60days

As you know, if you’ve been reading my blog, I have been working on a Medicare appeal to fight what I considered to be an early discharge from Medicare in late July when my dad was in rehab for a pelvic fracture. I had appealed twice and had lost those appeals and was about to go before an Administrative Law Judge to hear my case on November 3rd, when I learned about the 60-day rule.

IT IS VERY IMPORTANT TO KNOW ABOUT THIS RULE.

When my dad fell again at the end of September and fractured his hip, which required hip replacement surgery and another round of rehab, I assumed that Medicare would consider this a separate incident.  With each incident, I thought, a person is covered 100% for 20 days and then from day 21 until day 100, a co-pay is charged.  If you have secondary insurance, that insurance pays the co-pay.

I assumed that since this was a different body part injured and that it was injured in a completely different time frame (and in his case, a different state), that the clock would re-set and he would have another 100 days to use for his hip replacement recovery. NOT TRUE.

MEDICARE RULES STATE THAT YOU HAVE TO BE OUT OF THE SYSTEM FOR 60 CONSECUTIVE DAYS FOR THAT CLOCK TO RESET. Otherwise, they just lump the second fall into the first and you are allowed to use whatever the balance of days you have left.  In my father’s case, it would have been less than 60 days.

As I was just about to ship off my documentation to the Administrative Law Judge, I learned of this rule. Amazingly, I learned of this rule because someone posted a story on Facebook about their own parent’s circumstance in response to reading my last blog  post.  This is exactly what I envisioned when I started this blog.

I CAN HELP YOU AND YOU CAN HELP ME. Please share this blog with your friends and family.  Information is power.

I will now withdraw my appeal to Medicare for the last incident.  Fighting for that extra week in July would mean that he would have been out of the system only 54 days. If I leave things alone, he’ll have been out of the system for 61 days, and therefore eligible for the full 100 days.

What to do if your parent gets prematurely discharged from rehab (and from Medicare).

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When my dad went  into skilled nursing following his pelvic fracture in June, I blindly thought he’d be there until he was well enough and ambulatory enough to go back home.  WRONG.  Sometimes (in fact, it is feeling like more times than not) you are not in control.

Here’s my story.

When my dad fell and went into the hospital, he went into a state of delirium, which caused him to go four days straight without sleep.  This caused a type of psychosis, which necessitated giving him an atypical antipsychotic (or as I have come to believe, a nursing home’s favorite drug).  This drug worked to get him sleeping, but had the unfortunate side effect of making him almost narcoleptic throughout the day as well.  Can’t participate fully in PT or OT when you are constantly drowsy and falling asleep, now can you?  Let me answer that. NO, you cannot.

What happened next was that the nursing home/rehab facility and Medicare discharged my dad after only 35 days of therapy for “failure to make progress.” When Medicare discharges a patient, they no longer pay for rehab services (or the room and board or medications you have enjoyed while at the rehab facility).

I WAS OUTRAGED.  So I appealed the ruling.  I also signed a document requesting that the facility continue to provide services while my appeal was pending.  Within a couple of days, I got notice that my appeal was denied.  DENIED???  Again, OUTRAGE.  I appealed again.  This time I sent in a more detailed letter presenting my father’s side of the story, figuring there was not way they could deny it this time.  DENIED AGAIN!

My next step was to contact the Center for Medicare Advocacy, a fantastic organization that works nationally on behalf of seniors who are facing injustice by the Medicare system. They have tons of information on their web site about how to appeal and what steps to take.  TGFCMA (Thank God for the Center for Medicare Advocacy).  I sought advice from a very knowledgable attorney from this organization, who told me that most cases are denied at the first and second level appeals.  My opinion? This is a way for them to weed out most of the cases, because most people wouldn’t continue on with an appeal.

They don’t know me.  I am like a pit bull when I feel an injustice has been made.  And there is no clearer injustice than in my dad’s case. So I appealed again.  This time, I will have a Skype conference with an Administrative Law Judge, on November 3rd, who will hopefully read through all the documentation I will provide.  Surely, SHE will do the right thing.  I hope.  Stay tuned.