Skilled nursing and PT

[DawnM]

I thought maybe someone here could address this.

Dad's facility had him assessed for PT.   He can't walk on his own anymore.  They don't use insurance at all and it will run $32 per half hour session and they have recommended 2 sessions per week.   

He was getting PT when he lived with us and it was fully covered by medicare.   I called his former PT guy and he said they aren't allowed into skilled nursing homes and that we have to use the nursing home's PT folks.

What in the world?    Does this sound right?    Sounds like a racket to me.   

Just a vent.

[Bnogo24]

Hmmm, I’m a pediatric PT. The price is quite reasonable, but I don’t understand not using insurance, unless Medicare only allows so many per year or per episode.

[J-rap]

A few thoughts:  First, I think long term care facilities only use their own therapists, probably for legality issues.

Then, when you say "they don't use insurance at all," do you mean they don't take insurance for anything at the facility?  Or just PT?

My understanding of Medicare in LTC is that it will pay for skilled nursing, but not custodial care (custodial care being bathing, dressing, etc.).  I would have thought PT and other therapies are considered skilled nursing though.  BUT, that's only if it's doctor prescribed, not just something you're requesting.  The medical staff there will decide if therapy is likely to result in improvements, or at least maintain function.  If they don't believe it will, then they won't prescribe it and Medicare or any other insurance won't cover it.  

Maybe they're allowing you to hire one at your own expense though?  If so, $32/half hour seems like a steal.  But, I don't understand why they're saying insurance won't cover anything if they're recommending it.

[LifeLovePassion]

Medicare should cover it if he has had a qualifying event like a fall, but a Dr needs to order it. When mom was in AL, we switched her primary Dr to the group that visited on site weekly and they ordered her PT after falling (and only so many visits were allowed as long as progress was documented). It was never just because the staff or us requested it. 

[Mrs Tiggywinkle]

I don’t understand the insurance thing either, unless the facility’s policy is just that they don’t accept insurance—but that’s weird.

It is possible Medicare doesn’t think he will benefit from PT. My grandmother just lost services like PT and OT because Medicare hasn’t seen the progress that they want to see. Medicare only pays if they believe the patient will actually improve due to the service.

I believe it’s typical for a facility to only allow their providers. 

[Spryte]

PT/OT at my parents’ facility is covered by Medicare and private insurance if it’s Rx’d by the doc and meets the requirements. If it doesn’t meet the Medicare/Insurance requirements, then we are offered the option of private pay to continue. My FIL often private pays for PT. His runs around $50 per session. Patients use the PT/OT that’s available within the facility only. 

Does the facility work with insurance at all, for anything? If they do not, then I guess this sounds consistent with their policies.

I hope the therapy helps!

[Katy]

I think he has to be improving in a certain number of sessions in order for Medicare to cover it. If Medicare won’t cover it, it’s because it’s unlikely to benefit him. Check with his doctor but I’m guessing it won’t help.

[TechWife]

If it is medically necessary Medicare should cover it, though you may need to do the paperwork yourself if the facility doesn’t accept Medicare assignment. I would ask  questions, though. What you think about the answers should determine whether or not you sign off on it. Things to ask:

Why was he evaluated for PT? 
Is this therapy medically necessary? 
What doctor will be signing the PT orders?
What are the goals of the therapy?
Anticipated duration? 
When will you get a written plan of treatment (care plan)? How often will it be updated?   
How will you know if the PT has really been there and how long they stayed? 
How will the PT communicate with you? How do you access visit notes?

If the facility doesn’t accept Medicare assignment, what are their rules about you engaging an outside agency that does for his PT?

 

Edited September 7, 2022 by TechWife

[City Mouse]

Yeah, I agree with everyone else that something seems off. My dad is currently in Skilled Nursing and has been getting PT, OT and speech therapy all covered by Medicare. The Therapists are all employees of the SN.

[DawnM]

Medicare 100% believes he will benefit from PT, but there are no providers offered at the facility who take any insurance AND they don't allow outside PT in, so we are stuck.

[DawnM]

8 hours ago, TechWife said:

If it is medically necessary Medicare should cover it, though you may need to do the paperwork yourself if the facility doesn’t accept Medicare assignment. I would ask  questions, though. What you think about the answers should determine whether or not you sign off on it. Things to ask:

Why was he evaluated for PT? 
Is this therapy medically necessary? 
What doctor will be signing the PT orders?
What are the goals of the therapy?
Anticipated duration? 
When will you get a written plan of treatment (care plan)? How often will it be updated?   
How will you know if the PT has really been there and how long they stayed? 
How will the PT communicate with you? How do you access visit notes?

If the facility doesn’t accept Medicare assignment, what are their rules about you engaging an outside agency that does for his PT?

 

He has been doing PT for a full year now and I can answer all of those things according to what his previous PT would do.   But I called his previous PT and they said they are not allowed to enter skilled nursing facilities and that facilities have their own that we have to use.   

Meanwhile, the facility says they only use this PT that contacted me, and they do not accept insurance at all.   They are private pay.

 

[DawnM]

Guys, I don't know what to tell you, this is exactly what I am saying, ALL of your responses seem logical and reasonable, but they won't work at his facility.   I have tried them!

Just to clarify, he only stopped PT because he went into the hospital with Covid and ended up in rehab and then a skilled nursing home.   It is a private pay nursing home, not medicare.

He has actually fallen IN the new facility, and broken his hand and bruised his ribs.   They absolutely think he needs PT and the doctor said he needed it, and they came to assess him and said he needs it, but "they" do not even bill insurance, they are private pay only.

I thought maybe you all knew if this was a normal policy or not but it sounds like it isn't.

Edited September 8, 2022 by DawnM

[LifeLovePassion]

6 minutes ago, DawnM said:

Guys, I don't know what to tell you, this is exactly what I am saying, ALL of your responses seem logical and reasonable, but they won't work at his facility.   I have tried them!

I thought maybe you all knew if this was a normal policy or not but it sounds like it isn't.

No, it is not typical from our experience. The facilities here make it a point to let you know that they work with Medicare providers for short and long term placements at 5 or 6 different facilities over the years for mom and dad. I'm sorry, that's frustrating for sure. 

[Mrs Tiggywinkle]

It sounds like this is a private pay only facility? If so, then no, no one employed with them/by then will accept insurance because that opens up a can of worms as far as Medicare is concerned.

IMO private pay only facilities tend to operate on a different set of rules. So what I’m familiar with at facilities who accept insurance will be wholly different than what you’ll experience there.

[TechWife]

That is not a payment arrangement that I’m familiar with. It does sound like he needs some help with fall prevention. You can still do the paperwork to file for Medicare reimbursement on your own. You’d pay up front like they are asking, get the medical necessity form from the doctor and submit that to Medicare with the bill and they would pay your dad for the allowed amount. Monthly filing would be fine. 

[DawnM]

6 hours ago, LifeLovePassion said:

No, it is not typical from our experience. The facilities here make it a point to let you know that they work with Medicare providers for short and long term placements at 5 or 6 different facilities over the years for mom and dad. I'm sorry, that's frustrating for sure. 

Let me clarify,  this is a private pay facility.   They do not take medicare at all to pay for the stay.   That might be the difference.   We are paying for dad's care with his funds.

[DawnM]

5 hours ago, TechWife said:

That is not a payment arrangement that I’m familiar with. It does sound like he needs some help with fall prevention. You can still do the paperwork to file for Medicare reimbursement on your own. You’d pay up front like they are asking, get the medical necessity form from the doctor and submit that to Medicare with the bill and they would pay your dad for the allowed amount. Monthly filing would be fine. 

Thanks, I will call them and ask about getting that covered.

[almondbutterandjelly]

I'm sorry they are being that way, Dawn.  My dad is at a private pay facility (Texas) but they willingly do the work to get as much covered by insurance as possible, as far as OT and PT and such.  They also allow outside PT in although prefer their own staff, who, again, are covered by insurance.  Your facility seems unusual, but maybe it's a Florida thing?