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True Story: The Case Of The Wandering Therapist – (Part One)

INTRODUCTION

 

 

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Remember: …we’re an electronic news magazine: devoted to the issues relevant to the general public, but especially those persons involved in Health Care Reform …

 

…our focus, among others, is to assist consumers, attorneys and medical practitioners: this in explaining new statutes and regulations, but on a more day to day basis, help those involved in Estate Planning, such that every effort can be made to provide for, and when possible, ensure, that for the disabled and older Americans, Nursing Home placement need not become a permanent “reality”:

 

…..we are thus walking you, consumers and concerned friends and relatives (again) through the alternatives to Nursing Home placement: we do this (here, in this issue) by demonstrating the huge benefits of Physical Medicine and Rehabilitation (PM&R): including (a) Physical Therapy, (b) Occupational Therapy, and (c) Speech Language Pathology: all of which, in some part, in some way, are covered services by Medicare:

 

…….here, in this issue of A Better Wrinkle, we look at the problems in accessing, on a timely basis, such care: …the legal/medical “setting”?  Point in time?  We are now living through a radically reduced number of Acute Care “Rehab” beds: because of the very low (new) reimbursement formula Medicare now uses.  But, there is a better “wrinkle”, a better way to access more aggressive care (rehab care) than any (ANY !!) Nursing Home will ever provide anyone !!

 

…..again: this article is directed at having you, your loved one, friend, anyone and everyone avoid using a Nursing Home, thinking that it, or any like venue, can provide the critical care needed.

 

 

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Part One

YOU CAN DO BETTER !!!

 True Story: The Case Of The Wandering Therapist

 

While under contract with a large California health care company, one that ran many, many free-standing (excellent) Acute Care Rehabilitation Hospitals, as well as Acute Care Inpatient rehabilitation Units (usually floors, in a Med-Surgical Hospital) a problem arose with one of my clients, out East.  There, I worked with an extremely talented PHYSIATRIST:  (pronounced:  FIZZ-I-A-TRIST):….that is NOT a counselor, or psychiatrist.  The word, Psychiatrist: (an M.D. who works with disorders of the brain, and much more): the two are spelled so alike that many lay persons fail to realize in a quick read-through, the difference.

 

PHYSIATRIST:  Obviously the word of the moment, and that I am speaking of, is derived from Physical Medicine, again, sometimes, simply referred to, as “PM&R”. There was a time when Physical Medicine and “Rehab” was not even covered at all by Medicare.  The problem today, which you will soon see, is that Medicare has DRASTICALLY, and RADICALLY reduced the number of dollars available for any kind of Medicare-reimbursed PM&R.  It is, in my mind, absolutely, “penny wise and pound foolish.”  (More on the $$$, Medicare reimbursement later.)

 

THE PROBLEM AROSE THUS:  I had a client whose family lived near my old Victorian farm house, back East.  Me?  I was in California when serious problems started to occur with regard to the kind of Nursing Home care my client could access, this when she was being discharged from an Acute Care Hospital, into a rural Nursing Home: there was only one N.H. in this rural county.

 

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FIRST CAME THE PATIENT’S DISCHARGE FROM A MEDICAL-SURGICAL FLOOR: this at an Acute Care Hospital.  Again, this patient was headed to a rural Nursing Home, soon to become one of their residents. Whenever a patient is transferred out of an Acute Care Hospital, the local, and I would think, all too often, custom was the following, to wit:

 

To transfer the patient out of Acute Care, attached to the gurney (ambulance transfer) are what are known as TRANSFER DOCUMENTS.  And even though my client had Medicare, and was going into a (Medicare) Skilled Nursing Home (bed), one with Medicare-Certified Skilled Nursing Home care, I was informed that the Hospital Discharge Planner, a Social Worker, had informed the family that on the top of the Transfer Chart, there had to be, quite simply, a Welfare Application !?!

 

A “Welfare Application”?

 

In the vernacular, I was being told that this Medicare patient, had to, MUST, fill-out (or more likely, have the family fill out) a MEDICAID application: for Nursing Home care.  What, you say?  And rightfully so. WHY ?  ANSWER:  My client was not eligible for any kind of “so-called” welfare, i.e., she ABSOLUTELY was not eligible for the state MEDICAID Program.  In fact, she had some small private resources, not many, but clearly, as I had finally screened her, I knew that she was eligible for MEDICARE, not Medicaid !!  Skilled (Medicare-paid) N.H. care (beds).

 

More particularly, my client was eligible for the Nursing Home’s limited number of Medicare-reimbursed beds (up to 100 days, per Medicare.)  I was, to say the least, rather incensed, almost irate, given that I knew exactly what TRICK the N.H had up its sleeve.

 

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MEDICAID DISCRIMINATION:  Simply put, know this: there is a RADICAL difference in the amount of money ($$$$$) which Medicaid will pay for a “regular” (NON-SKILLED) Nursing Home bed: as opposed to having the Nursing Home reap the benefits of admitting someone NOT eligible for Medicaid, and thus paying for care, PRIVATELY !!

 

Private Paying Residents versus …..Medicaid Reimbursed Residents.  It was then, and REMAINS:  all about the $$$ !!

 

PUT ANOTHER WAY:  Except for 100 days of Medicare-reimbursed Skilled Nursing Home care/beds (which Medicare pays for up to and including the 100th day of any stay, or “Spell of Illness): Nursing Homes care is not paid for by Medicare !!!!.

 

More on a ‘Spell of Illness’ later.

 

OTHER LITTLE KNOWN FACTS ABOUT NURSING HOMES:  FIRST, every resident has the right to have her OWN physician: not the corporate doc the facility has on a low-pay retainer.  Why?  Corporate docs (really) provide little oversight of the facility: rather, show up every 30 days, talk with the DON (Director of Nursing): then check a box in each chart, which says the patient, if on Medicaid, CONTINUES to be eligible for another 30 days: for reimbursement by the State’s Medicaid Program: which pays Nursing Homes, again, far, far less than any private pay patient: and far less than the Medicare-Reimbursed (all) Skilled Nursing Home beds.  Medicare is the payer of first resort, unless there is some kind of silver-plated Insurance Policy, and which stands in front of Medicare, per the Skilled N.H. beds, care.

 

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AGAIN: Medicare has virtually nothing to do with Nursing Homes, except for the FEW adults, who are SO VERY ILL: that they require the most Nursing Care available, in any N.H. with Certified: Skilled Nursing Home beds, which come with Medicare-reimbursed therapies, and SKILLED nursing.

 

HOWEVER:  All care, including therapies, MUST have an M.D.’s ORDER: for exactly what care, what Nursing, and what “REHAB” therapies are to be performed on the very, very ill new resident, just discharged (some PREMATURELY) from the Acute Care setting.

 

Reference in this publication our discussion of premature discharge: given that the Acute Care hospital is usually paid the exact same (LUMP-SUM PAYMENT): for the same diagnosis, the hospital patient is treated at the Acute Care level: AND: Recall: The hospital is paid the same amount of money, say for an 89-year old patient, Hip Replacement, regardless of whether she is in Acute Care for 18-hours, OR: For 18 days !!!!  Note: See above blog/issue re the Diagnosis-Related way in which all 89 year old patients are grouped together: and it is the hospital’s decision to DISCHARGE this frail elderly patient (usually): whether or not they are REALLY stable and ready for discharge.  Some remaining Acute Care Rehab Hospitals even have their very own, say, renovated MOTEL: now converted into an outpatient (not hospital) setting: thus allowing the hospital (corporation) to collect the LARGE-$$$$-figure for the HOSPITAL surgery (the LUMP-SUM PAYMENT): while billing at a much lower rate (the only rate allowed) at what is now referred to as SUB-ACUTE CARE: the “motel” in Florida, particularly, and some in Texas, that I know of, personally: these PREMATURE DISCHARGES FROM ACUTE CARE REHAB, have actually killed several of my clients.  Why?  Go figure: then ponder the two levels of care: and the avaricious (greedy) health care systems Medicare (legally) allows, etc.

 

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SO:  Back to my client, now a resident of a Rural Nursing Home: and in need of very skilled care, post-surgery.  She was thus  admitted to this Nursing Home as a Skilled Nursing Home patient, resident.  AGAIN:  Why are her SKILLED needs relevant: they are and remain the ONLY gateway into SKILLED NURSING and/or SKILLED REHAB care which is paid for, at the Nursing Home level of care: this by Medicare.

 

FURTHER:  As proof that such a resident (patient) is REALLY in need of this higher level of care, it is available under Medicare, paid for by Medicare, ONLY per the following, to wit:

 

MEDICARE REGULATIONS:  Provide that before ANY patient coming into a Skilled Nursing Home (bed) must as proof of how seriously ill they are, FIRST: be treated for three (3) days IN AN ACUTE CARE HOSPITAL: immediately preceding their entrance into any Skilled Nursing Home Wing (or Skilled Nursing Home bed).  Such is the legal prerequisite, the requirement before (even if in a Skilled Nursing Home bed): especially if Medicare will actually, truly pay for such care, in the N.H. setting.  Note:  Many Nursing Homes do not even have ANY Skilled N.H. beds !!  Fortunately, in this rural jurisdiction to which I am referring, the sole N.H. in this rural county, DID have Medicare-Certified Skilled Nursing Home Beds.  And it was there, that my client’s Nursing Home “story”, a real “trial ….” , begins ……

 

IF ALL THIS SEEMS STRANGE, just not right: then you are, in all likelihood, looking at a situation which is not fair, AND: the manifestation of poor Public Policy (law and regulations).

 

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SO:  what are you, a family member to do: regarding any such Premature Hospital Discharge: …or TOO EARLY discharge to Sub-Acute Care ???

 

ANSWER:  You must grab the reigns, and act.  If something doesn’t seem right, it probably isn’t, e.g., premature discharges from Acute Care Medical-Surgical Hospitals, or Acute Care Rehab Hospitals.

 

Now, do you see the GREED !?!?

 

As a good attorney friend once told me:  “Bert, if it doesn’t SEEM right, then it probably is not !!!”  AND:  If it does not seem right, THEN IT IS PROBABLY ILLEGAL !!!

 

Let me say it AGAIN:  Premature Discharge from any Acute Care Hospital is illegal:

 

It’s ILLEGAL, under Medicare: but for all practical purposes, you, the family, are the only ones (usually) who can get it together to file an eviction APPEAL from Acute Care, by way of PART ONE AND INTRO  AUG SEPT  2015 Medicare’s  appeal  process: this alone buys you two more FULL hospital days.

 

ALSO:  If after a Premature Discharge (or what appears to be): and then, later, the patient is readmitted, within 30 (thirty) days: of the original DISCHARGE: guess what!?!?

 

ANSWER:  The Hospital automatically gets, suffers a complete REVIEW and FULL AUDIT of the… (likely) Premature Discharge.

 

END: Part One:  Part Two follows, NEXT.