Calling Charbie, nursing home/insurance question

[lliang_chi]

Hey Charbie,

I know you work on the administration side of a nursing home. Not sure if it's admittance or what.

Background: my MIL has been recovering from an accident since January. She was released from the hospital to a skilled nursing facility for 90 days, then transferred to a rehab hospital for a few weeks, then discharged from the rehab hospital 5 days ago for surgery and is now recovering post surgery in the same hospital her procedure was done. We're trying to get her back into the skilled nursing facility she was in before (she still has 10 days left of her 100 days), but we're having trouble getting insurance to sigh off. Her surgeon has written a doctor's order that she should be released to a skilled nursing facility, and then eventually transfer home. However the insurance is denying admittance. My DH thinks it's because the rehab hospital might have discharged her as a "discharge to home", so the insurance company might be holding onto those discharge papers, saying she's ready to go home, she doesn't need skilled nursing

I think she isn't far from being ready to go home, but we'd just prefer to have her in a skilled nursing facility until she fully recovers from surgery then come home.

Anyway, my question to you,

1. Is there anything we can do to change the insurance decision? Insurance has the doctors' orders that MIL should go to skilled nursing. We're going to try to get the hospital therapists to say she also needs therapy, as an additional argument.

2. If we pay for skilled nursing out of pocket, what else are possible charges on top of room and board? E.g. are nurses visits charged? Doctors visits? Supplies?

3. If we pay for the skilled nursing out of pocket, will that effect how much Medicare will pay for her home care once she's ready to transfer home?

Thanks,
LC

 

[charbie]

There are a number of factors that go into this...can you get my email addy from PS admin so I can ask some specific questions about what insurances she has, etc.? I think she has grounds for appeal, but if she has Medicare she shouldn't have any issue at all due to her having skillable services required. Depends on what is primary, Medicare or Insurance. Id be happy to help you sort things out, since it sounds like she should be able to use those last 10 days of her Medicare benefit.
As for private pay...that will include room/board, meals, routine nursing care (but not supplies), but not things like meds or therapy. However, again, depending on insurance, she may get some of those items covered even if they wont pay room and board.

Youre right that this is right up my ally...what I do for a living is nursing home admissions

 

[lliang_chi]

Charbie,

Thanks *SOOOO* much for your response. My DH just called and said she just got approval for skilled nursing.

If it's alright with you, I'd like to still ask the PS Admins for your email. I'm sure I'll have a some more questions when we get to the point that she's ready to transition home. I know it's a little bit different than what you do, but you have such good insight I'd really appreciate it.

I also want to add that I've been tempted to post something like this for the past few months that MIL has been in recovery. From the TTC and preggo board, I figured you'd be a great resource, but everything has been going OK up till now I didn't feel I had to. When the insurance denied her admission, I was feeling really desperate and sought your opinion.

Thank you, thank you, thank you!

~LC

 

[charbie]

Charbie,

Thanks *SOOOO* much for your response. My DH just called and said she just got approval for skilled nursing.

If it's alright with you, I'd like to still ask the PS Admins for your email. I'm sure I'll have a some more questions when we get to the point that she's ready to transition home. I know it's a little bit different than what you do, but you have such good insight I'd really appreciate it.

I also want to add that I've been tempted to post something like this for the past few months that MIL has been in recovery. From the TTC and preggo board, I figured you'd be a great resource, but everything has been going OK up till now I didn't feel I had to. When the insurance denied her admission, I was feeling really desperate and sought your opinion.

Thank you, thank you, thank you!

~LC

Yayayayay! I love when people are able to use the insuance they thay have PAID for! Plus us saavy (or desperatee for patients...however you want to look at it) admissions people will go to any measures to try and admit a patient

Thanks for the compliment please get my email address. I would be more than happy to help, since the system is so screwy and even I can have a hard time navigating through things and this is my job! But there are so many resources, so whatever insight I can provide or if I can help point you in the right direction, well then I've done my duty as an informed citizen