Mom had a knee replacement and reconsideration appeal (2nd appeal) was denied. It took 8 days to review and they said she is liable for payment for the 8 days she has been in rehab during review process. She has Medicare and Anthem PPO insurance.
I believe it depends on the information provided by your mom's rehab. If they are encouraging her discharge, then, in my opinion, it's probably not feasible to have Medicare approve the appeal. That was the case in my father's situation when he was in rehab. I tried everything for both appeals to get approved - got doctor recommendations for my father and I was very extensive on providing very elaborate feedback for consideration - and both times were denied.
In researching this, I learned that it's a very small percentage of appeals that are actually approved - unfortunately. I hope you receive a positive outcome for your mom's recovery ~
The SNF/Rehab that my father stayed at made false statements about his progress to have him discharged after he made an appeal to stay. Right now he’s on the hook for a little over $1k for 72hrs that went past day 21 at the facility… Oh, but I documented everything. I’m just beginning the process of having his insurance company review what the SNF/Rehab was up to during his stay. Generally, Medicare follows their rules & makes decisions accordingly. However, the upper management at these SNFs will lie, cheat & steal with giant smile. What I’ve observed has truly changed my view of all nursing facilities. If the neglect & apathy don’t get you, the fraud & deception sure will.
Last year, she fell and broke her right leg which resulted in three surgeries, last one due to an infection. She also needs the right knee replaced but the surgeon did not feel comfortable doing it due to the extent of her injury. He only agreed to do the left knee. So she is working with two bad knees, one is healing and the other needs a replacement ( bone to bone, very painful to walk and her right leg is "windswept" ). Recovery took her longer because of this. She is being discharged now, but they said she would be liable for payment from 1/9-1/18 because the second appeal was denied.
I've had three inpatient rehabs in the last two years. I had no trouble with Medicare approving. All three went over the 20 days that Medicare paid in full. I have BC/BS sor supplement and they paid everything else. I've not had Medicare refuse to pay for anything.
Why do you feel Mom needs more PT? If she went beyond the first 20days that Medicare pays, then yes she owes the 50% that Medicare does not pay. Her suppliment may pay for the balance or partial but with Moms supplement she paid $150 a day 6 yrs ago.
If Mom has reached a plateau or not progressing, Medicare would have her discharged. Why do u feel she needs more time? Knee replacements usually heal fast and people are on their feet soon after. People I know who have gotten PT its usually after they return home after the surgery and they go to a Therapy clinic.
In researching this, I learned that it's a very small percentage of appeals that are actually approved - unfortunately. I hope you receive a positive outcome for your mom's recovery ~
Oh, but I documented everything. I’m just beginning the process of having his insurance company review what the SNF/Rehab was up to during his stay.
Generally, Medicare follows their rules & makes decisions accordingly. However, the upper management at these SNFs will lie, cheat & steal with giant smile. What I’ve observed has truly changed my view of all nursing facilities. If the neglect & apathy don’t get you, the fraud & deception sure will.
If Mom has reached a plateau or not progressing, Medicare would have her discharged. Why do u feel she needs more time? Knee replacements usually heal fast and people are on their feet soon after. People I know who have gotten PT its usually after they return home after the surgery and they go to a Therapy clinic.