FAQ - Skilled Nursing Care Coverage
The following are answers to frequently asked questions (FAQ's) by concerned patients and their families when notified of their pending discharge. As an agent of the federal government we are obligated to enforce strict Medicare and insurance coverage guidelines.
Q- I was told that my skilled services were being discontinued. Do I have to leave the facility after the last covered day?
A- No, you do not have to leave.However, neither Medicare nor your insurance provider will pay for your stay any longer. Arrangements for private pay can be made through the social worker's office.
Q- Do I have the right to appeal the decision to stop skilled Medicare services?
A- Yes, you have the right to appeal our decision to the North Carolina Centers for Medical Excellence, an agency independent of Rex Healthcare.The social worker will provide a sheet with appeal instructions and contact information. Appeal decisions are made within 48 hours.
Q- I was told that I was guaranteed 100 days of Medicare Coverage. Why is my coverage being discontinued?
A- No person is guaranteed a specific period of time to receive skilled services. The need for skilled services is evaluated weekly and once a person no longer meets skilled criteria, payment by Medicare or your insurance provide discontinues. That does not mean you must leave the facility.
Q- How was it determined that I no longer have skilled needs?
A- The care team will meet once a week to discuss your care and progress. It is at that time that the decision to continue skilled care or to stop skilled care is made. The social worker will update the patient (and family if needed) to discuss the outcome of the meeting. Please notify the social worker if a family meeting is needed.
Q- What are skilled services?
A- Skilled services are those that require the professional competence of a licensed therapist or nurse. On going progress in physical, occupational or speech therapies, as determined by the therapy team, constitutes the need for a skill. Additionally, special dressings, certain medication therapies, training regarding care for a new diagnosis (diabetic teaching), monitoring of mental status and wound care can constitute skilled nursing care.
Q- Why is my private insurance coverage being discontinued?
A- Most private insurance companies will give an initial approval for your stay.If we recommend that you require more time, the social worker will contact your insurance provider to update them on your progress and they will either agree or disagree. In all cases we make every effort to assist the insurance provider in making the best decision possible, but are bound by their final decision.
Q- Is the social worker able to recommend facilities or agencies for after discharge care?
A- No, strict federal rules prohibit recommending specific agencies.We are able to provide resource information only.