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Topic Catch 22 - Medicare, SNF, and Hospice Go to previous topic Go to next topic Go to higher level

By searchlight On 2011.09.04 04:01
My father was in a nursing home, and while there, the day before he was to be discharged, he tried to stand up from his wheelchair, somehow tripped, fell on the floor and broke his hip.

Because of this incident, he had surgery to repair the hip, which went well, and then had to be sent to another nursing home for rehab.

At this point, he only had about 60 of his 100 nursing home days left. Six weeks into the program at the SNF, my father started to become paranoid, so the doctor readjusted his sinemet, and administered Seroquel to control the paranoia which did not work. The geriatrician then switched to Clozaril which really made him worse, so that was stopped, and back to Seroquel he went.

While all this was going on, he developed some Pneumonia and a UTI, which required anti-biotic treatment. A few nights ago, with only 4 Medicare days left, and a scheduled discharge date from the SNF of today 9/3/11, I received a call from his doctor that she was sending him to the hospital because he was severely dehydrated and confused, pulling out the anti-biotic IVs that she ordered.

My father is now in the hospital with the goal of stabilizing him, and sending him to a SNF for further stabilization and rehab, as he never had the benefit of proper rehab for the hip fracture. The problem is that we thought that his secondary insurance would pay for an additional 30 days in a SNF as they stipulate that Medicare days would have to be exhausted, he would have to be in a hospital for at least three days, which he is, and be admitted to the SNF for the same reason he went into the hospital. Two CSR's at the insurance company confirmed his eligibility now.

The SNF would have used the 4 remaining Medicare days and then turn to the secondary but as it turns out, that is NOT the case per the insurance company's pre-certification supervisors. For the secondary to pay an additional 30 days at 100% as it stands for my father's current situation now, my father would have to use up the 4 remaining Medicare days first, and then be admitted to the hospital. The mistake made by his doctor, was that because she did what was medically necessary to treat my father, the only way for him now to receive that extra 30 days from the secondary is for him to go back into the nursing home for 4 days, then be readmitted back into a hospital for medical treatment. The problem here is that he is already being treated, so the phraseology of the secondary insurance company's interpretation would create ethical questions for his doctor, and the hospital in order to satisfy the insurance requirement. Moreover, so far, no nursing home would take him for just 4 days.

So now, as of two days ago, the doctor tells me he is declining because of the Hip Fracture, Parkinsons, and the other ailments and has at best 6 months to live but you would not be able to tell by just looking at my father as he is not on any kind of life support, or pale in color. Right now, they are treating him with fluids to prevent dehydration, and two anti-biotics plus his usual pills including the Seroquel.

Again, this is the doctor's opinion. At the time she said that, he was very restless, combative, and refused to eat anything. The last two days, he is calmer, and eating some food.

My dilemma is that I have nowhere to send my father because the secondary will not make an exception to their rule despite my trying to appeal, and the only alternative is to consider hospice which limits the treatment they provide. I feel that regardless of my father's condition, he deserves a chance in an SNF, at best some rehab, at worst some respite care once he stabilizes. Agreeing to Hospice care as an alternative to placing him in an SNF would just be confirming the doctor's opinion, and in my mind, if he is declining, hasten his demise even faster because of the limited treatment that he would receive.

The spokesperson for the hospital, the Patient Advocate is very sympathetic and offers no resolution at this point other than to suggest Hospice, and Private Pay.

My father is a strict Pension earner plus my mother has Alzheimers, so the past several years my job has been to take care of them both at home with the limited resources that they have. I cannot afford to pay $300.00 a day for private care in an SNF, and taking home him now, as he is, is not an option.

Medicaid is out as his monthly income is above the limit.

Fyi, my father is a Veteran, and we considered the Veteran Hospital for treatment but the people there tell me that would be no guarantee that he would be placed in a Veteran's SubAcute rehab facility immediately, or any faster as there is a waiting list, and one has to apply. His community doctor suggested to me that while he is in the community hospital now to make application to the VA short term rehab facility. Maybe they will accept him.

I told the doctor that regardless of my father's condition, he deserves a shot at proper recuperation, and not be deprived of that chance because of circumstances. Like I said, the day that she told me he was declining was his second day in the hospital. Today, he appears to be better with some improvement.

I do want to be clear. My father is 91. I know Parkinsons is degenerative, that he has other underlying medical conditions at this moment, and that he broke his hip which for people his age is usually fatal. But if he has a chance at some recovery, and even the doctor admits that there is a very slim chance, I want to be able to give him that chance than be forced to deprive him of it because of an insurance company's narrow interpretation of their rules. The goal here was to stabilize him if possible in the hospital, get him another 30 days in an SNF, and while he was there, apply to the VA SNF who would be able to give him another 90 days if accepted as there are no Medicare days available because of the 60 day separation rule between benefit periods.

As of now, I am at an impasse. Any suggestions?

By parkinit On 2011.09.04 11:21
As far as the VA is concerned, here is the Caregiver hotline information: The National Caregiver Support Line will be open Monday through Friday 8:00 a.m. to 11:00 p.m. and Saturday 10:30 a.m. to 6:00 p.m. Eastern Time. The National Caregiver Support Line Toll-Free number is 1-855-260-3274.

They hooked me up with a regional social worker who has helpful in assisting with me finding help both inside AND outside the VA, so I hope you are equally as blessed with a caring social worker.

It may be worth having someone in the legal field review his insurance policy as well.

By searchlight On 2011.09.04 12:04
Thanks for the VA information. Much appreciated.

Update: I spoke to the nurse this AM. My father ate some of his breakfeast, and cracked some jokes with the nurse. A first.

Here is a man on his deathbed(declining fast)??

I know what is inevitable but the doctor's description or rather how she describes his condition now, leaves much to be desired.

By susger8 On 2011.09.05 08:20
I don't have any suggestions on how to get him covered for the SNF, but I wanted to say that my dad broke his hip at age 86 and it was looking pretty bad, but in spite of being in the late stages of PD, he recovered amazingly well. He was in the rehab center for 5 weeks afterwards -- I think they sent him home too soon. But in less than a year he was fully strong in that leg with no residual pain. On the other hand, he lost ground mentally from the anesthesia, hospital stay, and time in the rehab center.

I don't think it's at all impossible that your father could recover from the break.


By searchlight On 2011.09.10 04:04
The latest update to this situation is that I persevered with my father's secondary, this time speaking to a manager who finally understood that my father did meet their requirements. That being said, they approved 30 days in an SNF.

However, after 30 days, if he still needs to be in an SNF, my only recourse is to apply for institutional Medicaid as he is still out of the Medicare Benefit period, not being in the community for at least 60 days.

The SNF he is now in, does not accept Medicaid, unless my father spends downs his liquid assets, if he had any. He does not. He is just a pension earner, and a renter, so I have to search for another facility that accepts "medicaid pending" patients. All I want to do is give him one more chance at recovery.

In the interim, my father does not look good. Very thin and frail. He still is not responding to conversation like he did over a month ago. He tends to facially freeze, and hallucinate at times. He is still on the UTI and Pneumonia antibiotics. The doctor adjusted his Parkinson's medication.

To tell you the truth. I go to sleep at night always expecting the final call.

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