My questions are the following: My
mother went to a nursing home and had medical and AARP: which they took
her in without question. They also sent her within the week to a mental
hospital which now makes sense for they wanted to generate the skilled
nursing 100 days while she also was pending for Medicaid. Dec to April
they sent her twice to a hospital; in April , due to incomplete
paperwork, she was denied medicaid; but her private insurance was billed
and paid due to her hospital stays. April the nursing home reapplied
which she was approved in June.
Now here is my question: Medicaid
noted on the approval they could "Retro" the billing (isn't this to only
be 3 months max?) The nursing home actually went back all the way to
Dec. eventhough they were paid already by medicaid/AARP. With the
paperwork from medicaid they told us the monthly payment would be
$1070.00 each month and they went back retro this fee to Dec 2009 and
are now trying to collect this amount from her family eventhough private
insurance had already paid; she was denied in April and started the
application over. This does not seem fair? They are forcing us to
sign a promisory note for the balance due on her account becuase they
"Retro" the monthly. This means, the nursing home got paid first by
private insurance, 2nd billed medicaid, and now want us to also pay the
medicaid obligation monthly fee.
What should we do? I have
contatacted the nursing home office, their corp office and Medicaid who
doesn't seen to understant the were billied 10K which was already paid
by my mom's private insurances; they don't seem to want to bother even
when I sent them a 20 page report with rejunggled billing statements.
Your help would be most appeciated, Thanks you!
When your mom went into the NH, did the NH take her in "Medicaid Pending", or was she admitted as private pay with medicaid to be applied for later?. Someone from the family signed an admissions document on her - which is it? This will make a huge $$ difference in the billing for the "gap" between admission and medicaid approval. AND how was the admission form signed, did a family member just sign their name or was it signed "XYZ as DPOA for ABC". Again this will make a huge $$ difference for responsibility.
You say "she had medical and AARP: which they took her in without question"
I'm assuming you mean she had Medicare and one of the AARP plans as a secondary health insurance or was it AARP LTC insurance. Medicare doesn't pay for NH stay but will pay for some parts of the medical & rehab aspects of her care in the NH. If she had a LTC policy with AARP it pays for some of her stay but I don't know of an AARP policy that pays for NH in it's entirety. Maybe someone does and can comment on that.So there will be a daily living fee the NH needs to bill to somebody. What the amount is depends on her level of care AND some NH have a set limit on that daily rate which is in the admissions contract. Again this is very important as if it's $ 80 day maximum daily rate then that's it but if it is a variable rate it could be $ 150 or $ 200 or whatever the market will bear. If she is approved for Medicaid, then Medicaid pays for the daily rate but if she is declined then she's private pay at their rate.
The money the NH is going after is the daily rate gap that isn't covered by a LTC policy & will be expensive no matter what or where the NH is.
Say her NH does not do "pending" admissions and mom is a $ 200 day rate resident/$4,500 mo.... but she is denied Medicaid, then they can bill you for the difference between her personal monthly assets you submitted for the Medicaid application and should have been paying for the months between admission and when she was finally accepted into Medicaid.
Some NH require a direct deposit of all her assets and put her personal in a kitty at the NH, other's you can send a check in, it really depends. If it is a direct deposit, make sure it is going to the NH. Someone in the family would have gone
either to SS office or on-line to do that, so there should be a record of it.
Has the NH been getting a check monthly based on her assets? If not or you all are late in paying, they can do a 30 day notice to you all that she needs to find another place. This is serious as once this happens other NH won't want her either. Is this why the promissory note?
You say her Medicaid application was denied. Why was it denied? Did you file an appeal? Was it done within the time required? If it was because financial or other personal items were missing or incomplete in the application, that is the responsibility of whomever signed her in. If she was denied because she was "not medically necessary" then the NH works that appeal through as they have the items needed for that appeal.
One thing I've found is that most don't realize the Medicaid approval for NH has to be both financally and medically necessary in order to pay for the NH.
When you applied for Medicaid, you or the family should have filled out a lengthy set of paperwork and provided documents (bank statements, burial policies, insurance poicies, SS annual statement, annuity EOY document, citizenship, etc.) based on a list required by the state to qualify. If her application gets denied because some of that is incomplete then the NH will come after you to get the $$ difference as you are responsible to get the documents done and not the NH. Just as you are the one to file an appeal if Medicaid is turned down for financial reasons. Some NH file the application for you and most are really helpful in the process but the documentation required must be provided by the family.
It is alot of stuff and can go back up to 5 years, but that's the state's requirements and not the NH and you have to comply.
What did the caseworker cite as the reason for the denial?
Yes the state will retro for 90 days from the date the application was received. If there is a gap of longer than for approval/denial that it's really unusual.
I think you need to determine exactly what the NH is billing you for.
I would send a certified letter with return registered mail (RRM - the green card) via the USPO to the director of the NH and to the Director of Patient Finance at the homeoffice of the NH. Keep it 1 page and say that you are totally confused as you thought her policy # 1234 and her policy # 6789, which has paid a total of $ yxz
for her care, was the total amount due as of whatever date. Also put in that all of her assets less her personal allowance is being paid monthly (put in the date and check # for each month, e.g check # 678 2/4/11 $ 1,740.00 cleared 2/10/11).
That you cannot figure out what the balance is for and can they please break down the charges. Keep it to 1 page.
20 pages is just too much for an inquiry letter.
If you signed her in as "XYZ as DPOA for ABC, then you are not personally responsible for her debts. But if you didn't, then your are. If you live in a filial responsibility state they can come after you. Is this why the promissory note?
If you find that dealing with the paperwork is just too complex, then contact your local agency on aging for help or get a certified elder care attorney.
If she was denied due to questions on money or if someone has been trying to finiggle her money or assets and hide it from Medicaid or if there are large amounts of money taken from her accounts over the last 5 years and you cannot account for why then she will be denied till that amount is used up and paid for by family till she hits the 2,000 maximum. Remember you signed an approval for the state caseworker to go through anything & everything.
Mistakes are often made by the caseworker too. They really don't get paid very much and have huge caseloads. Most of the mistakes I've heard about or seen have been about VA benefits paid to spouses or more unusual financial issues, like how to deal/explain with oil & gas lease revenues or ranches as homesteads.
Medicaid application process is just way to complex but you got to slog thru it.
Good luck.
Also after accepting the private they also billed medicaid during the same period; doesn't that seem a bit muchj? and because they retroed it the also want us to pay the monthy starting/retro back to December, this is where I think the money prob is. thanks so much!
If a NH accepts Medicaid, then they agree to whatever your states Medicaid policy is for facilities. My mom is in TX and TX HHS reimburses the NH on a daily rate based on a monthly cap. I moved my mom from 1 NH to another and the reinbursement was prorated for 27 days to 1 NH and 4 days to the other NH and neither she nor I was responsible for the other days. But when my mom was in a private pay IL and moved from there to NH, she was according to her contract responsible for a 30 day advance notice to the IL that she was moving and would be prorated to pay in full any days if before 30 days. I did the notice and then she moved 33 days later so she owed them for the 3 days that she "over stayed".
She was lucky as IL had like 3 vacancies so not an issue. But could have been