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Can the Nursing Home Stop Billing Medicare for My Mother's Treatment?

  • October 1st, 2015
Q
My mother spent four days in the hospital and Medicare approved 100 days of skilled nursing facility care after her stay. After 48 days, the nursing home cut off her therapy and ended her Medicare benefits, without notifying us either in writing or by phone. She was not discharged from the nursing home, however, and we have received a bill for the final 51 days of care. This was our first notification that the nursing home was no longer billing Medicare. The physical therapist said that my mother has reached the level she was at prior to her hospital stay, but she is still receiving treatment at the nursing home for the same condition she was hospitalized for. The nursing home said it's too late to appeal their decision because we are outside the 30 days. Is this legal? The therapists said Medicare would deny any further treatments because she regained the ability to feed herself and to push her wheelchair with her feet. Is that true?
A

Based on the information you provide, your mother may well have grounds for appeal. The facility should have provided her with a Notice of Non-Coverage prior to terminating Medicare. They may have and your mother may not have known what it was or what to do with it. Ask for a copy and information about whether and how it was given to your mother. It will give you information on how to contact the Quality Improvement Organization for your region, which monitors these issues and appeals. You are too late for an expedited appeal but I’d be surprised if you can’t appeal at all. It sounds like you have one or two issues to argue on appeal: potentially lack of adequate notice, and certainly based on what you say whether your mother should have been terminated prior to the full 100 days. For more information, go to the Center for Medicare Advocacy website which provides a self-help package for appealing Medicare skilled nursing facility denials. 

For more information about Medicare appeals, go here: http://www.elderlawanswers.com/can-you-appeal-if-medicare-refuses-to-cover-care-you-received--14429

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Last Modified: 10/01/2015

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