Hello. Need advice. My boyfriend is 53 and he had his leg amputated on May 14th. He was transferred to Skilled Nursing on May 24th. He has still got his stitches in, waiting to see the surgeon, on pain meds, doing PT and OT, however they presented him with the Medicare non-coverage letter after today. He's was told it would take he would be in there 10 weeks possibly, and I'm wondering why they didn't tell him this sooner, they said he could have appeal, and he has, he has not gotten his prosthetic yet all he has done is been able to stand a couple times with assistance. He lives with his daughter who works and he has been practicing going down the hall with the wheelchair. He has been able to transfer from bed to chair and sometimes chair to bed. Do you see this as them justifying he's ready for outpatient treatment? or in home? Just based off this has anyone else been sent home that soon? He was on IV antibiotics until till 4 days ago. Thank you so much.
Have him contact the social worker at the facility for help. Make sure that he and his daughter meet with the discharge planner to set up home health aides, nursing care and therapy. Medicare will pay for that.
I don’t think it’s an unreasonable DC. They have to move him out due to insurance rules.
If he is able to do what you say it’s time for him to try outpatient PT. What else can they do? Now it’s up to the patient to do the work to get better.
If he can’t then maybe apply for community Medicaid for NH placement but from what you’ve said he is progressing nicely.
I am surprised that he is being released so early for an amputation. The PT alone should take more than the 20days Medicare pays 100% for. What is the reasoning they are giving for the discharge? Has he hit a plateau? Maybe the facility is not equipped to give him the full physical therapy he needs? My friend, who lost a leg, was in a specialized rehab. They actually had a car so he could learn how to get in and out of it.
I agree, call his surgeon and tell him what is going on.
participate.
Chelly, seems he is on SS disability. As such, he receives Medicare and maybe Medicaid. Medicare determines how long you will be in rehab based on the reports that the Therapist sends them. All he can do is appeal the finding. There have been members who have been successful. Hopefully they will chime in.
What that means is that Medicare isn't making the decisions, the insurance plan is. To see the difference between original Medicare and Medicare Advantage there is a 15 minute Medicare Class video (free) at http://MedicareQuick.com/Class that explains it pretty well.
Fortunately, there is an appeals process for Medicare Advantage Plans. Step one is to file an appeal with the insurance company. Make it an emergency appeal so they have to give an answer right away. Additionally, he can't be discharged while an appeal is in process.
There are several levels of appeals so be sure to continue to the next level if he is denied.
Also, ask about the Ombudsman program. This will vary by state, but it's an agency that deals with complaints against nursing home facilities.
And if he's on Medicaid, see if there is someone in that office that can assist. Additionally, if he is 100% full share of cost (meaning he doesn't pay anything) and your state allows it, he may want to dis-enroll from the Medicare Advantage Plan and go back to original Medicare, with Medicaid paying the co-pays and deductibles of Medicare. Obviously you'll want to talk with someone who knows the ins and outs of your state prior to doing this, because there is on limit on your potential costs with original Medicare.
Finally, if there is a Legal Aid in your town, or nearby, contact them to see if they can assist as well.
Hopefully, you'll get some relief. I'm sorry that the two of you are going through this.
You get what you pay for.
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Why was his leg amputated? Was it a scheduled or traumatic amputation?
How much does he weigh?
There is a whole bunch of pre-prosthetic training to prepare the residual limb for a prosthetic. He can't be fitted for a prosthetic until his wound heals and his socket is built. Where is he in the process? That he's in a wheelchair "practicing going down the hall" suggests to me that something is not progressing the way it should.
There are certified peer mentors who offer valuable support to people with amputations.
What you are describing is normal. I know it is scary, but it is normal. He can continue to heal at home. Once his stitches are out, he will work with his prosthetist at an office. PT appointments can begin to practice walking. I also practiced falling - to learn how to get up.
I read through all the other comments. They are trying to be helpful, of course. However, unless one has actually been through this, one can't know. The hardest part may be that going home is very scary. Again, quite normal.
There are several amputee sites on Facebook. Reach out to one or more.
I do know there are certain criteria that need to be met, and once they are met, Medicare will discontinue coverage. It is likely that being able to transfer and "get around", however minimal that might be, along with less or no need for specialized nursing care (IV antibiotics, wound care, etc) were the deciding factors.
That said, the Medicare website DOES state this:
"Physical therapy
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Note
Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year."
So, he should be able, through his doctor, to arrange PT at home and/or once he is more mobile, at an outpatient facility. He might also qualify for help with medical equipment that will help him at home.
I haven't had to do rehab, but I was on IV antibiotics as well as TPN (intravenous feeding.) I HATED being in the hospital and pushed enough that they finally sent me home after almost 4 weeks with home nursing coming in to set up the feed bag, clean and change the dressing around the IV port and draw blood to test for adjustments to the antibiotics. Supplies (antibiotics, TPN and various items like gloves, cleaners, etc) were delivered on a regular basis. There were 2 different ones, both multiple times/day and I was provided with the antibiotics and a pump, which I was able to do myself. At the time I was not on Medicare, but it should be similar.
Best of luck to BF! May he work hard and get back to as normal as possible soon!
In California, the law requires a skilled nursing facility to provide a patient with a 30-day notice to vacate and even then, there must be a safe place to go to - assuming he is still qualified. Make sure you have a medical assessment. If he's already appealed, Livanta, the agency who handles the appeals, is supposed to give him an answer I believe within 48 hours. What was their decision?
Improvement Standard, that is the name of your issue. Traditional Medicare covers up to a 100 days of in-patient rehab services. 20 days at 80% and the 80 days at 50%. However, the patient needs to participate in therapy and show improvement.
He can appeal. However, failure of the appeal means that he would need to pay the facility. If he has that kind of resources to take on that financial risk, then you should ask the facility for an estimate for private pay now. They may have a better rate if he pays direct and they don't submit to insurance.
In appeal, he would be arguing that he is continuing to improve and therefore Medicare should continue to grant coverage. Typically a lawyer won't have much value to add. You can read more about this issue at the Center for Medicare Advocacy, medicareadvocacy.org.