Dear Carol: My mom, 87, suffered a fall three months ago and has been having physical therapy in her assisted living facility. She was doing well with the rehab, but then from a medical perspective, she stopped making progress. So now, even though she needs this therapy to stay stable, the facility says that Medicare will no longer cover the cost. Is this true?
It sounds like a stupid rule since she will slide back and then need therapy again but meanwhile, she will suffer more pain and be less mobile. I like the facility and they are doing a good job overall. I know a move would be hard on her and could even set her back. Do you know if the facility is right? — GD.
Dear GD: I’m sorry about your mom’s situation. Patients being denied physical therapy once they’ve stopped showing improvement has been a frustrating issue for years. It shouldn’t be, given that the problem was resolved through a lawsuit that was decided in 2013. Still, unfair denials continue.
Some happen because a facility chooses not to follow through with Medicare since denial is easier. Some happen simply because as with all health insurance, there are a lot of regulations in Medicare. This is necessary, of course, but it’s a lot for administrators to handle. Sometimes, administrators know the rules but others in the chain of command don’t. Sometimes the denial is legitimate.
I’m not a Medicare professional, but I will offer you public information.
This is the lawsuit:
“Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate the potential for improvement (known as the “Improvement Standard). On January 24, 2013, the U.S. District Court for the District of Vermont approved a Settlement in Jimmo between attorneys for the Jimmo plaintiffs (the Center for Medicare Advocacy and Vermont Legal Aid) and the Centers for Medicare & Medicaid Services (CMS).”
What can you do? First, remember that you are pleased with the facility overall, so try to talk with various administrative people there about your concern. Maybe this can be resolved with more communication.
Other than that, your choices are to move your mother to a different facility, just accept this as truth, or fight it — which is time-consuming but often effective. There are two “toolkits” that people can use if they choose to follow up.
- Nursing homes: https://medicareadvocacy.org/toolkit-medicare-skilled-nursing-coverage-and-jimmo-v-sebelius/.
- Home health: https://medicareadvocacy.org/toolkit-medicare-home-health-coverage-jimmo-v-sebelius/.
Over time, facilities and care agencies should get the message, so again make sure that you've done what you can to work with them. Understand, too, that if the therapist says that therapy won’t help your mom stay more mobile, you may not have a case.
Whatever you choose to do, it sounds as if you are a terrific advocate for your mom.
Carol Bradley Bursack is a veteran caregiver and an established columnist. She is also a blogger, and the author of “Minding Our Elders: Caregivers Share Their Personal Stories.” Bradley Bursack hosts a website supporting caregivers and elders at www.mindingourelders.com. She can be reached through the contact form on her website.