For many years, Medicare has stopped paying for therapies or skilled care once the patient stopped improving, or plateaud. This is not what the regulations say, but somehow that became the practice across the country.
In December, the good folks at the Medicare Advocacy Project fought and won against this trend, and a federal judge ordered that nursing homes must now provide the full 100 days of coverage that patients are entitled to, so long as they need skilled care or therapies, whether to improve, to maintain their conditions, or to stop or slow a deterioration.
So what happens to patients who have received Medicare denials in the past few years, and had to pay out-of-pocket, often impoverishing themselves, so that they (or a loved one) could receive continued nursing home care? Will this federal case help them?
Yes. Denials going back as far as September 20, 2010 can be re-reviewed under the new (old) standard. So if you or a loved one were in a nursing home in the late summer of 2010 or later, and if you had to pay out-of-pocket for skilled care or therapies after a Medicare denial, then dig out your paperwork. As the federal case is implemented, Medicare will create a process for re-reviewing these denials in light of the new (old) standard. Check the Medicare Advocacy Project for updates on this process.
If you have a loved one currently in a nursing home and they receive a Medicare denial, if you think they need continuing skilled care or therapies in order to maintain their condition or to stop or slow their deterioration, then appeal. It will take some time for the appeal process to get up and running, but you want to make sure you appeal on time.
P.S. These rules also apply to home care and outpatient therapies.