Question for Medicare experts

[thewold]

Here's the situation. Have a client who was recieving skilled care at home for neuoraphathy which was paid for by Medicare. At the same time, his wife had a knee replacement and could not help with his ADL's and needed someone to come in a night and help him get to the bathroom, etc. So, the daughter had an agency come in and stay at night to help with his activities of daily living. The daughters were there to do it during the day.

Problem is, they used an agency that was not Medicare approved. Now they have a $3500 bill. My understanding is, had they used an approved facility for the informal care, Medicare would have paid as long as he was also recieving skilled care, correct? He is also confined to home so that settles that requirement.

Has anyone had any experience with Medicare still paying a claim even from a facility not approved by them? My client called Medicare about it and they told her to have the facility send it to Medicare and they would pay. The facility said they won't do this. I called Medicare and they told me to fill out a claim and send in the bills and they might pay it.

Any and all opinions or experiences would be appreciated.

One final rant on this, they have spoken to many of the medicare approved facilities and they say they don't provide informal care, only skilled care in blocks of one hour. Who is a client supposed to recieve the informal care from during skilled at home care if the medicare approved agencies don't do it and the agencies who do do it aren't approved. It seems kind of screwed up to me.

 

[Frank Stastny]

Here's the situation. Have a client who was recieving skilled care at home for neuoraphathy which was paid for by Medicare. At the same time, his wife had a knee replacement and could not help with his ADL's and needed someone to come in a night and help him get to the bathroom, etc. So, the daughter had an agency come in and stay at night to help with his activities of daily living. The daughters were there to do it during the day.

Problem is, they used an agency that was not Medicare approved. Now they have a $3500 bill. My understanding is, had they used an approved facility for the informal care, Medicare would have paid as long as he was also recieving skilled care, correct? He is also confined to home so that settles that requirement.

Has anyone had any experience with Medicare still paying a claim even from a facility not approved by them? My client called Medicare about it and they told her to have the facility send it to Medicare and they would pay. The facility said they won't do this. I called Medicare and they told me to fill out a claim and send in the bills and they might pay it.

Any and all opinions or experiences would be appreciated.

One final rant on this, they have spoken to many of the medicare approved facilities and they say they don't provide informal care, only skilled care in blocks of one hour. Who is a client supposed to recieve the informal care from during skilled at home care if the medicare approved agencies don't do it and the agencies who do do it aren't approved. It seems kind of screwed up to me.

I believe the main reason the care agency will not send the bill to Medicare is that they know that if Medicare approves the care the amount they pay will be substantially less than $3,500.

However, if Medicare would approve it, I believe it would not be a benefit under Skilled Care. Skilled care is only for recovery and the patient MUST be showing daily improvement or Medicare will stop paying the benefits.

I know, it can be argued that going to the bathroom is definitely something that dramatically improves one's "health" on a daily basis. I just don't think that Medicare perceives it quite that way. haha

His would probably be a "claim" for Home Health Care. As I understand Medicare, his doctor would have had to order Home Health Care for him and it definitely would have had to be by an approved agency.

The first thing the daughter should have done is to "check with their agent". That is our job, to ferret out the information, make sure it is correct and then advise the client.

Why do most people believe that they know more than we do? Bottom line, she screwed up royally. Serves her right for not checking with her agent.

Her daughter probably isn't the brightest light bulb in the box or has more money than Ramiz and Rick put together. Can you believe that anyone would approve that kind of service and not ask how much it was going to cost and if Medicare will pay for it?

 

[Bob_The_Insurance_Guy]

(BANG) (BANG) (BANG)

That's why people/families should get LTC coverage before they get into this situation.

(BANG) (BANG) (BANG) - me banging my head against the wall.

I would suggest getting hold of an eldercare attorney. Unless someone here has specific experience, I would be afraid to comment on such a personal and financial issue.

Mom and Dad have no LTC. The daughter's FEEL they can't afford LTC, and the cycle continues.

 

[thewold]

The thing is, the doctor did order the skilled care. His condition had gotten bad, the doctor ordered the care (occupational and physical), the agency approved him for 60 days and did not approve him past the initial period. He got to the point where his condition would not improve further and therefore Medicare would not cover it, so they quit the skilled care. It was only during this time of skilled care that he also received the informal care.

After reading up on the home health benefits under Medicare, it states that Medicare will cover the costs associated with informal care only while the patient is receiving skilled home care. The problem is, no medicare approved agencies provide informal care, only skilled.
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Also, these folks do have an LTC policy but have not satisfied the elimination period. The days that were provided will go towards the elimination period but won't completely satisfy it.

My question is, if medicare supposedly pays for informal care while someone is recieving doctors ordered home health care, how do you get around the approved agency requirement if no approved agency does informal care. My ultimate goal with them is to have Medicare pay for as many of the elimination period days as possible with as little as possible out of pocket expenses.

 

[Bob_The_Insurance_Guy]

My WAG:

Medicare will not pay, if there is no further improvement. That is where a Med Supp Plan would have added some coverage.

The whole idea being:

Medicare pays for the initial treatment, until no further improvement, then the Med Supplement takes over for a while. All this occurs during the Elimination Period of the LTC Plan. Then, the LTC Plan takes over.

Now, enough ranting on my part. Whenever you are going up against the government (Medicare), go with an eldercare attorney. If you can't afford one, join PrePaid Legal for $35/mo, and have one assigned to you.

Be prepared for a fight, but a fight you MAY win.

Good Luck.

 

[Frank Stastny]

Medicare pays for the initial treatment, until no further improvement, then the Med Supplement takes over for a while. All this occurs during the Elimination Period of the LTC Plan. Then, the LTC Plan takes over.

This is a common misconception. Medicare, under the Skilled Nursing provision does not pay for any other care than skilled nursing.

So many people have told me that an agent has told them that Medicare will pick up the first 100 days if a person has to go to a nursing home and "that ain't right". Medicare will not pay a penny if the person goes to a nursing home because they can no longer take care of themselves, the ADL's.

Some agents just plain lie about it to lower the cost of the LTCi premium, others don't know any better because they have not done the research themselves. They probably just heard another agent or their "manager" say that.

Skilled Nursing is for recovery from an illness or injury as long as the person is showing daily improvement, not because the person needs daily help with the ADL's.

Nothing "occurs" during the "elimination period" except the policy holder pays for the first 30, 60, 90, or 100 days of their nursing home stay. When I sold LTCi I was always very specific when I explained this to the prospect. More than once the prospect told me I was wrong because another agent said that Medicare and their supplement would pay for the first 100 days.

The most difficult part of my job is that I have to follow the agent who preceded me.

Oh, another reason people believe that Skilled Nursing will pay if the person goes to a nursing home for care is that a lot of small hospitals contract with a nursing home to provide things like therapy for things like a broken hip or speech therapy for those who have had a stroke. Since they are "in a nursing home" it is assumed that it is "nursing home charge". It isn't and does not fall under the Skilled Nursing provision of Med Supp policies.

 

[Bob_The_Insurance_Guy]

Frank,

You're right.

I was not paying attention when I responded.

 

[GreenSky]

Informal care means that while the PT in in the home, they can help the patient go to the bathroom. It does not mean that while getting skilled care Medicare will pay for someone at night to help with custodial care.

 

[thewold]

I don't think that is entirely correct, below is straight off the Medicare site as to what Medicare will cover for home health.

• 
  [*]Home health aide services on a part-time or intermittent basis. A home health aide doesn’t have a nursing license. The aide provides support services for skilled nursing care. These services include help with personal care such as bathing, using the toilet, or dressing. Medicare doesn’t cover home health aide services unless you are also getting skilled care such as nursing care or other therapy from the home health agency. The home health aide services must be part of the care for your illness or injury.

In this particalar situation, the patient was on the wrong mix of medication that was causing him to lose motor skills. Once he got off the medication his motor skills started returning. His doctor ordered PT/OT to help him get back to walking and taking care of himself. During the 60 days of PT/OT, he was still having trouble getting to the bathroom at night and was having to go a lot due to a urinary infection. Family ordered a home health aide to help a few nights a week, less than 8 hours and less than 7 days a week, which would we intermittant. Therefore this should have been covered according to Medicare.

Problem is, after reading up on this, the home health agency has to include this in his plan of care, and hire or work with another agency to provide all the care the patient needs, as long as it is on an intermittant basis. They only provided the skilled part but he did need some help with ADL's which in my opinion should have been part of his plan of care.

 

[policy doctor]

P-sssst...WOLD...you need to understand the jargon Medicare uses for these benefits. Some are defined in the back in your "GUIDE TO MEDICARE" book. Some LTC policies define the terms also. That eliminates some confusion.

Another hint....try your local ombudsman, or even Area Council on Aging. You could start with a local senior center if you have one, or call the state for a resource guide.

Gotta agree with the poster who said the daughter should have checked out the prices and payor before ordering services.

"Hey Waiter....whaddya mean this bill is $75!! All i got was some chicken, wine, and salad."