non-certification skilled nursing

[Sherry43]

What is the name of your state (only U.S. law)? CA A retired friend of mine who lives in PA and has health insurance from her employer in CA was admitted to a nursing home earlier this year following severe flu. She is 83 years old but does not have Medicare. She lived with me for several years, has Parkinson's disease and needed help with bathing, cooking, etc. While she was in the nursing home recovering, I went for surgery, had a heart attack, and was in the hospital for 11 days. During this time her insurance carrier (Anthem Blue Cross) said she no longer needed skilled nursing care and denied certification. She had no where to go and could not ambulate or take care of herself. She had to stay at the nursing home without insurance coverage. This lady also has mild dementia. Her family did not fight the denial, and four months later I am trying to deal with the problem. The nursing home wants to be paid--her sisters advised her months ago not to pay. She has about $40,000 in cash but needs this in addition to her retirement to pay for her stay at assisted living as I can no longer care for her. Does she have to pay the full amount to the nursing home? I would appreciate advice on how to deal with this.

[lkc15507]

Originally Posted by Sherry43

What is the name of your state (only U.S. law)? CA A retired friend of mine who lives in PA and has health insurance from her employer in CA was admitted to a nursing home earlier this year following severe flu. She is 83 years old but does not have Medicare. She lived with me for several years, has Parkinson's disease and needed help with bathing, cooking, etc. While she was in the nursing home recovering, I went for surgery, had a heart attack, and was in the hospital for 11 days. During this time her insurance carrier (Anthem Blue Cross) said she no longer needed skilled nursing care and denied certification. She had no where to go and could not ambulate or take care of herself. She had to stay at the nursing home without insurance coverage. This lady also has mild dementia. Her family did not fight the denial, and four months later I am trying to deal with the problem. The nursing home wants to be paid--her sisters advised her months ago not to pay. She has about $40,000 in cash but needs this in addition to her retirement to pay for her stay at assisted living as I can no longer care for her. Does she have to pay the full amount to the nursing home? I would appreciate advice on how to deal with this.

Owww. Big fat Oww. Of course she will owe the nursing home--the full amt. She and / or her estate eventually. I can't quite divine the time frame, but she needs to appeal the denial by Anthem. No idea the type of plan she has, but there will most assuredly be an appeal procedure under that plan. Written appeal. Forget phone calls. Even if she is beyond the timely filing limits and appeal limits, try it anyway. TImely is often easily defeated. Anthem is a notorious pain in the a__. Why did Anthem deny? Med Nec? Homebound? Those are my first guesses, but jeez o pete, anything is worth an appeal. Hard work, research, and a bad assed attitude go a long way.

PS, can't stress enough, why did Anthem deny the SNF? Website for CMS has much info about homebound--gen definition only, review case by case. Med Necessity, same animal.
lkc15507

[ecmst12]

SNF's are for people who are actively recovering from an injury or illness. If they cease to improve after a certain point, then a SNF is no longer the correct place for them, they need a long-term care facility, which may not be covered by her insurance. Long term care is a step down from skilled nursing. So after the rehab stopped helping her, that is likely when her insurance stopped paying for it.