Good morning!!!!

[buckeyefarmer]

Got a new cat. Wife got it from a “rescue” group. Not that friendliest, I prefer the neighbors kitties, they are super friendly.
It doesn’t like the basement, but gets into everything.

 

[txdon]

Thanks for all the prayers! My mom's catherization went well, they said the blockage was at 90%, and they put a stent in.

Now I'm having trouble with getting the next phase of skilled nursing rehab care authorized. Her doctor is frustrated about it. So far I've been transferred by 2 people to other people and still waiting on hold. They said wait time is 32 minutes, due to Covid problems.

Has anyone had to appeal an insurance medical denial? I believe she needs 24/7 care for maybe 2 weeks or so.

My mom's situation:
92 yo
lives alone
family over 100 miles away
home not ADA compliant
can't go to restroom or take bath by herself yet
still on O2
has blood in urine

I appealed for skilled care for my father. Medicre declined skilled nursing rehab after the facility reported no improvement after 2 weeks. I completed the appeal form and won on a technicality. I made my appeal a day before July 4th and the facility had to respond in 24 hours. Since that included the holiday, the deadline was not met and my dad got another 2 weeks.

Is your mom able to do physical therapy? If so, that should qualify her for at least a week or two of skilled nursing care. Other things that would qualify her would be IV therapy or injection, wound care...anything that requires a LVN or RN rather that a general caregiver. Unfortunately, not being able to go to the restroom or bathe herself doesn't qualify. I would focus on the physical therapy. Unfortunately, since my Dad did not progress with physical therapy, he ended up having to go to a nursing home.

 

[txdon]

Don, sounds like excellent progress but “wife maid” aslip I’m sure

Good catch.
However it is allowed only on Fridays when she calls in the maid (herself) to clean the house and pays herself the going rate.

 

[txdon]

I was in the Physical Therapy waiting room waiting for the therapist to come in and they were all there except Egore. I was really hoping he had come down with covid and one of the dainty therapist would work with me today. But then the room shook and he made his thunderous linebacker entrance, with his shaved head, rolled up sleeves on arms as big as thighs, evil eyes and smirk hidden behind his mask. I told him that I walked a mile yesterday and my leg was still red and swollen and might need to do an easy session today, and his reply was just a smirk. So far not good.

He put me through the warm up exercises and on the bike I was surprised I could not pedal all the way around. I asked him if I had pedaled this close Wednesday because if I had I'm regressing because I cannot do it - probably because of my mile walk. He just chuckled and said he moved it closer that I'm not regressing. After the last exercise he pointed to the torture table and pulled out the knee flexion angle measuring device. I trembled.

He instructed me to lay on my back and pull my heel as close to my butt as possible. I pulled it back till I was almost crying and he s-l-o-w-l-y took a measurement . . . twice. I had to ask him what it was and he disspointly said 115˚. Then he disappointing said: "That's it see you next week". I was still in shock that he was not going to flexed my knee more to unbearable pain but apparently I was able to reach todays goal without his "assistance". I Felt like I dodged a bullet.

 

[buckeyefarmer]

Beats being in the snow.

 

[Kyle_in_Tex]

I appealed for skilled care for my father. Medicre declined skilled nursing rehab after the facility reported no improvement after 2 weeks. I completed the appeal form and won on a technicality. I made my appeal a day before July 4th and the facility had to respond in 24 hours. Since that included the holiday, the deadline was not met and my dad got another 2 weeks.

Is your mom able to do physical therapy? If so, that should qualify her for at least a week or two of skilled nursing care. Other things that would qualify her would be IV therapy or injection, wound care...anything that requires a LVN or RN rather that a general caregiver. Unfortunately, not being able to go to the restroom or bathe herself doesn't qualify. I would focus on the physical therapy. Unfortunately, since my Dad did not progress with physical therapy, he ended up having to go to a nursing home.

Thanks Don. She is being given PT. She is being given a diuretic, on oxygen, and has blood in her urine. It has boiled down to her doctor arguing "peer to peer" with insurance representative doc. I heard they get a bonus for denials....I guess they weigh the cost vs the risk of being sued. It's a game that they are pros at.
I wonder why physical fitness or the lack there of, doesn't matter?

 

[txdon]

Thanks Don. She is being given PT. She is being given a diuretic, on oxygen, and has blood in her urine. It has boiled down to her doctor arguing "peer to peer" with insurance representative doc. I heard they get a bonus for denials....I guess they weigh the cost vs the risk of being sued. It's a game that they are pros at.
I wonder why physical fitness or the lack there of, doesn't matter?

My wife said that medicare is very strict regarding skilled care versus custodial care. They have a list of what constitutes skilled care. It's sad but unfortunately medication and O2 do not require a skilled, licensed nurse. This may be why medicare is declining. Are you thinking that she will be able to go home if the blood in the urine resolves. If that is the case, maybe the doctor could argue that skilled care is needed to resolve the blood issues.


"What’s SNF care?
Skilled nursing facility (SNF) care is health care given when you need skilled nursing or therapy staff to treat, manage, observe, and evaluate your care. Examples of SNF care include intravenous injections and physical therapy. Care that can be given by non‐professional staff isn’t considered skilled care. People don’t usually stay in a SNF until they’re completely recovered because Medicare only covers certain SNF care services that are needed daily on a short‐term basis (up to 100 days in abenefit period).
Skilled care is nursing and therapy care that’s so complex it can be safely and effectively performed only by, or under the supervision of, skilled nursing and therapy professionals.
Skilled nursing and therapy professionals include:

• Registered nurses
• Licensed practical and vocational nurses
• Physicalandoccupationaltherapists
• Speech‐language pathologists
• Audiologists
  Medicare doesn’t cover custodial care if it’s the only kind of care you need. Custodial care is care that helps you with usual daily activities, like getting in and out of bed, eating, bathing, dressing, and using the bathroom. It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters. Custodial care is often given in a nursing facility. See page 20 for ways to get help paying for custodial care. Generally, SNF care is covered by Medicare only for a short time after a hospitalization. Custodial care may be needed for a much longer period of time."

https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf

Kyle see page 23 for info on a fast appeal if you think services are ending too soon.
You are your Mother's medical advocate.

 

[Kyle_in_Tex]

Thanks Don. I believe she needs physical therapy for starters.

 

[txdon]

Also a good source of information is the hospital social worker. He/she should have an office in the hospital.

 

[sodamo]

Got the over the range microwave hood hung before leaving for town. Progress

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