My mother-in-law has been in a nursing home for about a month. She was in skilled nursing for two weeks and was then diagnosed (misdiagnosed) with renal failure. My sister-in-law, how has power of attorney, switched her to hospice care at that time. Two weeks later, the lab was repeated (long story, but my doctor brother-in-law requested this - then a week and a half later it wasn't done so several family members complained), and it turned out she's not in renal failure (the initial lab was done while she had a stomach bug with vomiting and diarrhea). So my SIL switched her back to skilled nursing - she'd been having physical therapy in skilled nursing but that was stopped with hospice. MIL has mobility issues due to severe arthritis, but physical therapy allows her to get out of bed. While in hospice, she was given meals, meds three times a day, and helped to the bathroom. Other than that, she laid in her bed all day.
Now my SIL says she's gotten a bill from the nursing home for room and board for the two weeks she was in hospice - ?? Her insurance (commercial primary with Champva secondary) pays for the skilled nursing at 100%, hospice is covered, but NH says "medical insurance doesn't pay for room and board,"
Is that correct? The nursing home never told us she'd be billed in hospice (whereas no bill in skilled nursing), hospice didn't talk to us about it, and nobody told us she could go home - we all didn't think she was capable. I understand that long-term care insurance is what you need for a nursing home stay, but I guess I don't understand how this whole hospice thing works. She decides to forego expensive medical care, opting for comfort care - that should make insurance happy, right? Now we're being told "thanks - now insurance pays zero!"
Is the nursing home billing wrong? Can we appeal? Any insight or suggestions?
Premiums refunded but co-pay was low (less than Medicare copay from SS). Her's is/was a federal BCBS plan so either way it's fed $$. Medicaid would be cheaper as they pay less for the same procedure.
NH Medicaid has to go retro to day 1 so that they can pay for room & board @ the NH from day 1. Neither BCBS or Medicare pays for the long-term NH r&b charges, that's only by Medicaid, or private pay or LTC. My mom went to NH from IL so she wasn't admitted on the Medicare paid "rehab" 21++ days situation which is how most go into NH.
Did Medicaid pay for the PT, OT, etc? (I certainly hope they did!)
For the period of 5 -6 mos while she was Medicaid Pending, BCBS covered lots of stuff at the NH, like PT and OT and equipment and ambulance transfers. But once she was on Medicaid and Medicaid was retroactive to Day 1 of NH admission, BCBS did a clawback on all the $$ it paid to the NH and any providers @ the NH from Day 1. A couple of the providers were pissy about it as BCBS pays a much much higher rate than Medicaid.
What a mess! Hopefully the nursing home gets paid and we're done (with that bill, anyway). Thanks for the advice on negotiating a discount, and also on a potential 30-day notice. We'll keed those in mind. I'll also let my SIL know to be careful to sign as POA. I think she's doing that. Actually, I think my MIL is signing for herself most of the time.
Hospice is a 100% Medicare covered service. But Medicare does NOT pay for any of the room & board costs related to being in hospice @ a NH. That either is private pay, Medicaid or long term care insurance. What can happen with LTC insurance is that the policy is worded such that hospice related costs are not covered as Medicare is the primary for hospice. Hospice since it is not skilled nursing is not covered under the LTC policy which requires skilled nursing.
You need to look at the NH contract that was signed off on to see what their appeal process is and follow that. BUT really you need to contact in writing her insurers to see what is included and paid for in her LTC policy.
Now if any of you signed her into the NH and signed off as being financially responsible by signing her in & under their own signature (and not as Jane Smith as DPOA for Ann Jones), then the NH will eventually come to them to pay the bill.
If that was your SIL, then she will be the one the NH comes after. If it was you or your hubby, then you get it. What happens after maybe 4 weeks if family seems to have done nothing but ignore this, is that a "30 Day Notice" will be sent to whomever signed her in. This is a total panic situation to be in, so you really want to avoid this. If she is back in skilled nursing and she & you all like the place and her LTC is back up and paying in full, then I'd negotiate with the NH to reduce the 2 weeks costs by 50% as she is going to be a good customer over time.
You know some NH will not take LTC insurance, my mom's NH won't - only does private pay and Medicaid and Medicare. Even though the LTC insurance will pay a much somewhat higher rate than Medicaid, they won't do it because the reporting required by the insurer from the NH is too much to be worth it and there are plenty of Medicaid patients out there to fill a bed when there is one available.