A skilled nursing stay following hospitalization may not only be scary, but could end up being financially draining.
Although your current Medicare plan may give you the best “bang for your buck” under normal circumstances, you may find that if you have coverage through a Medicare Part C (Medicare Advantage Plan), you may not receive the coverage you are entitled to in the event you require post hospitalization skilled nursing care. Post hospitalization skilled nursing coverage criteria is “governed” under Chapter 8 of the Medicare Policy and Benefit Manual and although Medicare Part C (Advantage Plans) are expected to adhere to this criteria, often times they don’t.
The rules and regulations regarding post hospitalization coverage are complex. I have a 100% success rate with assisting clients with the appeals process which has saved my clients an average of $550 per day when they continue to require skilled nursing services afte their insurance companies have determined they no longer meet the criteria today.
If you or your loved one find yourself in a skilled nursing facility, contact me today to discuss your Medicare rights.
The following are actual examples of instances in which a Medicare Advantage (Part C Plan) Terminated Coverage for Skilled Nursing Home Benefits and with my assistance, the beneficiaries won their 3rd level appeal status relieving them of financially responsibility and making the insurance company responsible for payment.
- 83 year old resident with surgical wound requiring daily wound care. Resident with history of infection to wound and unable to properly care for at home. Prior to appeal resident owed facility $15,950.00 for a 29 day stay. After appeal balance = $0.
- 94 year old resident requiring daily wound care and physical therapy. Prior to the appeal the resident owed the facility $48,400.00 for an 88 day stay. After appeal balance = $0.
- 79 year old resident required intense physical, occupational and speech therapy following a stroke. Prior to appeal resident owed facility $36,300 for a 66 day stay. After appeal balance = $0.
- 94 year old resident denied insurance coverage after being hospitalized for respiratory and heart issues. Resident required both physical and occupational therapy to regain strength and ability to walk and safely take care of himself. Prior to appeal resident owed facility $6050 for an 11 day stay. After appeal balance = $0.
- 78 year old resident denied coverage following a fall and hip fracture resulting in a hip replacement and needing physical and occupational therapy to regain strength and function so he could return home safely. Prior to appeal resident owed facility $8,250.0 for a 14 day stay. After appeal balance = $0.
- 81 year old resident required intense physical, occupational therapy following a stroke. Insurance denied coverage . Prior to appeal resident owed the facility $7,700 for a 14-day stay. After appeal balance = $0.
- 99 year old resident denied coverage following a fall with a hip fracture and requiring physical and occupational therapy. Prior to appeal resident owed the facility $4,950 for 9 days of coverage. After appeal balance = $0.
- 84 year resident receiving physical, occupational and speech therapy as well as nursing care to manage feedings through tube in the stomach and care to a hole in her neck from a breathing tube. Prior to appeal resident owed facility $15,950.00 for a 29 day stay. After appeal balance = $0.
- 72 year old resident required physical, occupational and speech therapy following a stroke and also required nursing staff to safely administer nutrition through a tube in his stomach. Prior to appeal resident owed facility $19,000.00 for a 36 day stay. After appeal balance = $0.
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