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How To Maximize Medicare Coverage in Rehab

How To Maximize Medicare Coverage in Rehab

Do you have a friend, family member, or loved one who was hospitalized for three days and then went directly to a rehabilitative facility? Would you like to know how to advocate for your friend or loved one? If the answer is ‘yes,’ read on. It is important to know what primary health insurance coverage the patient has. If the patient has traditional Medicare, then the first 20 days will be covered 100%. The next 80 days, if approved, will be covered 80%; the remaining 20% is the patient’s responsibility. If the patient has a Medicare supplement policy that could cover some or all of the patient’s responsibility.

​Here is a common scenario many people encounter:

Mr. Smith, age 84, is admitted to a hospital as a result of a fall that fractures his left hip. Mr. Smith has hip replacement surgery. He spends 7 days in the hospital. He is then discharged from the hospital by the doctor, who recommends physical and occupational therapy. Mr. Smith is transported directly to Best Care Rehabilitative Center in Sunshine Acres, Florida, where he will receive physical therapy and occupational therapy. Mr. Smith’s goal is to regain his energy and physical strength, strengthen his muscles so he can walk independently or, with the assistance of a cane or walker, and be able to return home to live.

On day 19 at Best Care Rehabilitative Center, the physical therapist tells Mr. Smith that he is not improving and that Medicare will not pay Best Care Rehabilitative Center. What can Mr. Smith do? He needs more therapy and would like it to be covered by Medicare.

Mr. Smith consults with an elder law attorney who explains that the Medicare law changed in 2021, and the standard is NOT whether he is improving. The standard is whether Mr. Smith needs skilled care and therapy services to maintain function, or prevent, or slow decline. Mr. Smith also learns that Best Care Rehabilitative Center should not make the decision for Medicare. Mr. Smith can demand that Best Care Rehabilitative Center continue to provide therapy services to him and submit their billing to Medicare to make a decision. Mr. Smith will need the support of his doctor to confirm that continued therapy is required and necessary in order for Mr. Smith to maintain his current level of function. In the event that Medicare denies the claim, then Mr. Smith would be personally responsible for payment (Mr. Smith can file a Medicare appeal). By knowing his legal rights, Mr. Smith can be an effective advocate and continue to receive therapy that will be paid for by Medicare.

Check out Stephanie’s “5 Top Elder Law Tips”: