I don't understand how or when that decision is made? She will be past her 20 days of paid coverage in a rehab this weekend.
She seems to be stuck at this level of almost, but not quite standing up straight. She needs to be able to do this so she can pivot and use the bathroom like she used to.
Does the rehab make the decision, or do they send reports regularly to Medicare, or how does that work? I tried asking the PT, and she just kept giving me a circular answer about how they track their progress regularly, but couldn't tell me the answer to the question I was asking.
Your Mom may never get back to where she was before. Her age will have a lot to do with how she progresses. It depends on how a hospital stay effected her. For a patient in their 90s, lets say, its...they are good till they aren't. Meaning a fall, pneumonia, etc can do them in even if they were doing for themselves before the hospital stay. Mom may hit a plateau where PT will no longer help her. Medicare will then have her released.
If Medicare or the rehab facility issues a Notice of Medicare Non-Coverage, she has the right to request a fast appeal. A patient advocate (sometimes called a case manager or discharge planner) at the facility can help her do that.
The rehab social worker should be able to assist with this.
You can't trust a care facility's social worker to do this. They are all in on the scam. The first priority of any administrative staff member of any profit-making rehab or care facility is to maximize profits for the facility. Or to talk in circles and give runaround anwers to protect the scams and the people profitting from it.
So here's what you do. Tell the PT to explain it to you in full detail (or get someone who can), demand to see the reports on how they're "tracking" your mother's progress, exactly how much rehab time she's given every day, and proof of how much they've collected from Medicare for her rehab services. Now, make yourself plain that either they can produce these things for you, or they will produce them for your lawyer. Their choice. You should absolutely be consulting a lawyer who specializes in elder law.
This is what I told the rehab my father was in. He suddenly became eligible for up to 100 rehab days. He received PT and OT for 30 days longer than they originally were going to give him.
When rehab and nursing home people give you circular, run-around answers it's usually because they're covering up some Medicare or some other kind of insurance fraud.
Realistically you want to have this done as it’s easier than waiting on snail mail. You need to have the initial determination notice placed into your Medicare account in order to file the appeal to the MAC for your region. It’s the MAC Medicare Adminstrative (outside) Contractor that does initial appeal. Most of the time it goes into the fast track review. So like 72 hours. If you don’t like the outcome, then you file the secondary appeal. Hiring an atty to this point, imho, is a waste of time & $. It’s the 2nd appeal stage that having an atty can be important as it can be heard before ALJ Administrative Law Judge. Your attorney asks for discovery and the ALJ sends out the request to the Nh. So the NH has to be responsive.
How a NH can get around dealing with ALJ heat, is they find something plausible to add to elders chart that was overlooked. The easiest is the elder became ill with something unrelated to the initial reason they entered the NH for rehab. Like they had a fever, or developed a rash or bedsore, got bad diarrhea. That somehow - just somehow - info did not make it from the notes at the nurses station to the therapists over in rehab unit. It was an oversight. So once it’s added, rehab can take this new info into account to request for and indicate why to Medicare via its PECOS portal that a reset for PT time should happen. Easy peasy way to buy an additional time.
This is for you to discuss with the Rehab Social Workers and with the "discharge planning" committee, as places are unique to themselves and within the laws they operate differently.
But there is a running account and charting of progress made. And it is very clear how much can be made, and often futile to go on in rehab and will not be covered by Medicare past a certain point given the patient diagnosis and prognosis, age and general condition.
As I said, every case is individual as his or her own thumbprint, so speak with the rehab discharge planners, PT and OT. You should have been already invited into care planning if you are POA, or the person who IS POA/next of kin should be. This is for discussion between them. They can also explain government coverage for rehab.
Good luck to you.
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