Those who accept Medicare as payment–meaning almost every hospital, almost every nursing home and most doctors and rehab specialists in the country–sometimes worry about being audited. Their records can be checked a year or so after they have billed for services, and been paid, for services. It might make an administrative person with such providers anxious–what if they have to pay back something to Medicare, after all?
Audits are smart and help reduce error and fraud. But if providers over-react and become too cautious because of audits those who use Medicare can suffer. This is so because for a long time an informal and improper metric has been used by providers, and the metric puts Medicare users at a real disadvantage.
Watch out for these old terms, still used at times now: “failure to improve” or “plateau.” Those terms have been used informally for a long time. You might hear it even now when you are trying to see about services for a loved one who has Medicare coverage. Coverage denials based on that alone are improper and unfair.
Those on Medicare who want more therapy or services, in hopes of maintaining some small part of their health or abilities, or better levels of care that might let them return home, have been often told by facilities or providers that Medicare wouldn’t help reimburse or pay for such services. Scary stuff, as many seniors would find it tough to pay for much in the way of such services themselves for more than a few weeks.
Medicare does not provide unlimited coverage, as we know. But be prepared to challenge some denials of care coverage if it seems proper. Remember, the “failure to improve” or the “he/she’s reached a plateau” is not the right metric. Actually under the regulation and law, maintaining a patient’s current condition or preventing or slowing a patient’s further decline or deterioration is a sufficient reason to obtain services.
Feel free to gently push back against providers if you are given this line, or call an elder law firm like ours to review the situation.
Rather than writing a full dissertation though, I suggest folks check this website–a feisty group sued (the case is Jimmo v Siebelius) to get clarification of this issue to help the aged and disabled, and here is their question and answer page about the issue: http://www.medicareadvocacy.org/jimmo-v-sebelius-the-improvement-standard-case-faqs/