My MIL is in an assisted living facility - she had a stroke in February - she is currently on Medicaid. She has been receiving physical therapy up until recently to help her get stronger and back to being able to walk, etc. - she currently uses a wheelchair but has been slowly progressing to where she can use a walker. I was just informed that her insurance will no longer pay for therapy as they have paid out the max they will allow. Without continued therapy, all of her progress will be lost and she is anxious to get better - she calls me constantly asking about this. Any ideas, suggestions would be appreciated. She DOES NOT have the funds to pay for outside therapy.
I’d suggest that you do this ASAP. Medicare has rehab as a covered benefit, whether it’s post hospitalization rehab in a facility or community based (which if she’s in AL it might be this).
But how & if it’s paid depends on
- “progressing”, she has to be meeting certain markers and this is written up in her health chart likely daily or every other day as to just what her progress is.
- “bundling of care”, what Medicare & the other insurers do now is place a $ cap on rehab care. If part of this has been paid by her secondary insurance, they will follow whatever Medicare does.... so if Medicare has 86’d care then they will also. The facility or the therapist gets a set amount for a total bundle of services. So if she uses it all up in 3 weeks, that’s it.
As she’s had a stroke, there was a care plan done for her and within it will be a listing on her ICD-10 codes. These codes have an established followup to happen & that insurers will pay for. And the insurance has prenegotiated what will be paid based on the codes. Not a lot of flexibility once codes are in her chart in my experience.
The PTs & OTs are pros and know how to judge these two and run therapy so that they dovetail. If your mom is no longer “progressing” and used up the “bundle”, it’s going imho to be impossible to get more care. You can file an appeal, but if her chart shows no progress, the appeal is toast. Again speak with therapist ASAP.
Now she may be able to get “gait training”. Gait training or gait maintenance is kinda standard for those in a NH (skilled level of care place). It’s not “rehab” per se, but usually twice a week 1-1 work with the Pt or OT or therapy assistant / aide on walking and keeping muscle strength & it’s in the part of the facility where rehab has all their equipment set up. Medicare and Medicaid will pay for this. My mom had this 2- 3 times a week in both the NH she was in. The issue will be probably for y’all is that she’s in AL so there's not a big fixed Rehab section with staff and equipment.
Really you’ll find the OT or PT can better explain what all this means for possibly getting more care for your mom. It may be that she will need an assessment done to see if she is better off in a higher level of care facility, like a NH, that has therapy staff & equipment so she can get gait work 2-3 times a week.
Given the mom has dementia listed, it could be plateau. Our mother is in MC, and following some knee pain, they came in and worked with her. I'm sure mom didn't work on the exercises between visits, but at least she worked with them. Much later, about maybe 8 months ago, she started refusing to stand or walk unassisted (she was already using a rollator.) Partly fear of falling, partly becoming weaker from not walking and being overweight to boot. Anyway, PT came in and tried various ways to get mom to work with them. Nope. She flat out refused, and with the last attempt told them THEY should do what she was being asked to do.
I did have to sign the discharge paperwork and had to laugh at the "goals achieved" statement on it! Goals? Mom's goals maybe, but not the PT. So, it isn't always a number that is hit, though it can be. There are several reasons why PT may end and you need to know what it is. If it is a number, usually that renews the next year, but obviously that is 6m away.
Given her dementia, would any PT/OT help much? Mom may think it is, but perhaps she just likes the companionship. Would it be possible to get some instructions from PT and maybe hire a less expensive aide to walk with her? Just getting up and walking, even with a walker, will help strengthen her - a little more each day. An aide would be much less expensive than PT, if you have to self pay. Certainly can't hurt to try - if you can find a place that will do 1 hr/day, she can walk a bit, rest, walk a bit, etc for that hour, hopefully increasing the walk and reducing the rest.
If Mom means she wants to get back to normal, that may not happen. Her walker maybe as far as she gets. I would question if its she got to the max or did she hit a plateau and Medicare will not pay. If the later, Mom is as far as she will get. It really comes down to her doing for herself. She knows what exercises they did. Walking with the walker will help strengthen her.
93-14= 79 days of rehab available.
The caveat on all of this is that the patient must be actively participating in the rehab program and the therapists must feel that they can continue to improve. Once they plateau, Medicare will not pay anymore.
If you have a Medicare Advantage insurance the length of time they will pay for rehab services is dependent on the contract of the covering insurance company. Even with this type of program the patient must be actively participating in the rehab program and the therapists must feel that they can continue to improve. Once they plateau, the insurance will not pay any more.
It will take 60 calendar days for the rehab clock to reset .
Now there are some LTC/HN that will help a resident with maintenance of physical activities by walking with them when they go to meals or activities or rolling a ball to them when they are doing table activities but this depends on the individual LTC and remember the CMA or CNA is not a trained (and therefore not a highly paid) therapist. I think the chance of finding this same service in an AL is rather remote because by definition the AL is only set up to provide an "assist" to the activities of daily living (ADL) although many have established MC units that are more fully staffed but not necessarily with qualified nursing (CNA/CMA) staff. Anything more than that falls under the auspices of the LTC
PT & OT aren’t gonna beg and cajole them to get up and participate. Either MeMaw gets with the system or gets NCC’d & rehab stopped. Sometimes family can cheerlead enough to get them motivated but if not and they flat won’t do rehab, it’s over.
The OP is on MEDICAID and resides in an Assisted Living facility.
Please scroll ALL the way to the top, to see the ORIGINAL QUESTION, posted by "Hirshy 1230."
BTW, That "Not making progress," excuse was eliminated in 2013 (Jimmo v. Sebelius).
NOW Medicare + Medicaid are telling stroke survivors to argue with that facility for PT + OT, to maintain that resident's physical and psychological well-being.
If any therapist tries to utilize the "Not Making Progress," FIGHT against that "not making progress," bullsh*t
Our facility always terminates physical therapy and occupational therapy for Medicaid + Medicare stroke survivors, (always 5 weeks b/4 their Medicaid "re-certification").Even though CMS pays for PT+OT within their (per diem) daily rate $$$ paid to the facility.
(Medicare/Medicaid) CMS has repeatedly stated individually each of our denied residents/patients arere still eligible for PT + OT. BUT our facility continues to deny in-house services, to all CMS stroke survivors
OFF-SITE-->SOLUTION
(Medicaid/Medicare) CMS will pay for off-site therapies. Talk to Medicaid/Medicare about Off-site PT+OT at an outside physical therapy place.
At our facility Each (who was denied therapies) obtained PT and OT off-site, fully covered by CMS. (Medicaid/Medicare),
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BUT our in-house therapy office will block new prescriptions for off-site therapies. by telling neurologist that the resident isn't "making progress" or has reached a plateau. Sidebar: "Not Making Progress," is an old outdated excuse overturned, ejected out of the vernacular of CMS (2013 Jimmo vs. Sebelius). But many still incorrectly utilize it.
WHY is our corporation blocking therapy? Perhaps ...Money has been the reason for terminating therapies. Each therapy is terminated for different false excuses. The list of excuses is filled with inaccurate statements (outright lies). That were documented by various agencies as being inaccurate.
I watched a former administrator block a resident from obtaining transportation to an off-site PT/OT place.That administrator stood by the front blocking access to transportation. It was bizarre.
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All in all
1. contact that "insurance" Medicaid CMS directly. Learn how that facility is paid and what that payment includes. And the duration of a stroke survivor's therapies
After you have clarified DIRECTLY with the "insurance," the status of PT + OT.
(sidebar: PT +OT for stroke survivors is normally ongoing).
2. Find out where Medicare/Medicaid will pay-for her PT/OT off-site LOCATE/FIND that Off-site PT+OT at a physical therapy place
contact the off-site facility, schedule an appointment, arrange transportation or bring her to that off-site location.
I'm expecting you to learn exactly what each of our residents learned, that your mother is still eligible for PT +OT, Talk with her Neurologist to get him to write an ongoing PT +OT prescription.
Did the days max out, or did therapy not
re-certify her to continue therapy?
Maybe ask the social worker if there is one
at the assisted living office, or call local agency
on aging to see what resources they may
suggest.
Otherwise this may be where family and friends
need to step in and help her with therapy exercises
if possible. It's not the same as a professional, but
certainly better than no therapy, no exercises.
Ask her current therapists for instructions (they
usually have the standard pre-printed ones).
Use those, even if you are only there 1 or 2 days
a week and no one else can help out, that is
better than zero days a week.
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