Nursing Home/Long Term Care/Home Care/medicare 100 days - New York
My father entered a nursing home after 4 days in the hospital.
I got a call from the nursing home that they received a letter he
they were stopping coverage in the home because he did not required skilled nursing. No one told me the PRI had been set for 37 days. How can you pre-determine his need in advance?
I'm trying to get records. In the meantime did a first and 2nd appeal that denied by IPRO and Maximus. I just assumed he had the 100 day irregardless. I was hoping to hear from Medicaid
within this time frame but have not heard back yet on my nursing home medicaid application. I applied for community medicaid and by the time I got that he was in the nursing home. I don't want to take him out because he has severe sundowners and was keeping me and my daughter up all night. I can't go back to that. Any suggestions on how to fight this. WhenI called today, they say the next level is administrative law judge. This bites!!
Good evening. I am sorry to hear of the challenges you are facing regarding your Dad's nursing home bill payment.
It does seem that you are following as many avenues as you can regarding reversing the determination of if he qualifies for his bills to be paid or not. I do agree the key seems to be getting his record from the hospital to see if maybe they missed something that may qualify him.
While you are waiting to get his records, and while you are waiting to see the administrative law judge; you may also want to contact the Ombudsman for the area that your Dad is in. The Ombudsman is a person well versed in the laws and regulations that is to act on the behalf of people who are in licensed facilities (Assisted Livings, Nursing Homes, etc.) and act as an advocate. You can contact the Ombudsman for your Dad's area by contacting the State Department of Elderly Affairs (or a name such as this for your state that handles all affairs for Seniors - Maybe under the Department of Social Services). Ask for the contact information for the Ombudsman. You may be able to search for the Ombudsman directly on the Internet. Their services are free of charge and they will give you advice based on current laws and to the best interest of your Dad (not the best interest of the facility). The Ombudsman may be able to determine if there was a mistake made in the determination or if the determination is correct.
Additionally, there are many tips available that help families cope with the symptoms of sundowners syndrome. If you find that you have to bring your Dad home there are many things you can do to help your Dad to cope with Sundowners and also to help with him getting his days and nights mixed up (or just being up all night). Besides searching for tips to help your Dad with this syndrome, you could consider getting a night sitter. When I owned a sitter service we quite often had elderly clients that did not sleep at night. We could help the families by allowing the families to sleep while we stayed up with their loved one to be sure they were safe and care for through out the night.
I hope that some of these suggestions may be helpful to you. I wish you the best in your pursuit to have your Dad's determination reversed!
If you have any further questions, you are welcome to contact me directly at Ginelle_LeBlanc@bellsouth.net
With Warm Regards,