The Healthcare and Payer System – from the Consumer Side

The Healthcare and Payer System – from the Consumer Side

On April 2, my 92-year-old father sustained a fall in his assisted living facility (ALF), which resulted in an emergency department evaluation. Fortunately, he hadn’t broken anything, but he incurred a massive hematoma over his right hip. He was discharged and then had a second fall on April 5. His hematoma was then even larger, large enough to impress this ex-emergency physician, and he had multiple skin tears. His hemoglobin had dropped almost two more grams, and he was admitted for blood transfusions and intravenous iron transfusions for his symptomatic acute blood-loss anemia. The first hurdle was justifying inpatient admission.

A recent study suggests that 30 percent of nurses in the U.S. are considering leaving their profession. There is already a significant nursing and ancillary staffing shortage, and we experienced it firsthand during this ordeal. I had a house full of guests for Passover. I could not spend the amount of time I usually do at his bedside, advocating for him. My dad is not a complainer, and couldn’t recall how to summon the nurse, so I was constantly reminding the overworked nurse that she needed to ask him if he was experiencing any pain from his ginormous hip hematoma, so he would agree to getting up and walking. She was constantly reminding me that there were several sick patients on the floor commanding her attention. The reality was that much of my father’s needs could have been met by the aides, but my father is never enough of a squeaky wheel to get grease from anyone.

“Deconditioning” refers to changes in your body which result from inactivity. A patient can get fatigued, be short of breath on exertion, and find themselves unable to perform their activities of daily living. It can arise after only a few days of inactivity, and it takes three times as long to recover as it took to become deconditioned. After two to three weeks of immobility, an elderly person can lose half of their muscle strength.

The aides kept telling me that physical therapy hadn’t authorized them to get my father up and walking. In fact, the first morning, when I tried to get him to the bathroom expeditiously, an aide refused to help because he was a “two-person assist,” and the aide retreated to the nurses’ station, where I overheard him say that they might need to call security on me. But I persisted, because what my dad needed was to get up and walk. I just wanted to get him out and back to his usual surroundings, where the resident assistants at his ALF could help him mobilize and ambulate and get back to baseline.

However, the head nurse at my father’s ALF refused to accept him back without a night-sitter. That was not feasible to arrange at 2 p.m. on Good Friday, so he stayed over Easter weekend to be discharged on Monday to a skilled nursing facility (SNF), per physical therapy’s (PT’s) recommendation, to rehabilitate and gain strength and mobility. During that weekend, they left him in a chair for 11½ hours straight. I’m going to advise you all that if you find that there are issues in caring for a loved one, bring it to the attention of the charge nurse, the nursing supervisor, or an administrator. I understood that they were short-staffed, but that was dangerous. Can you say “pressure ulcer” and “hospital-acquired condition?”

This will not come as a surprise to many of you, but the staffing situation at the SNF was even worse. It is easier to state that PT hasn’t cleared a patient for walking and transport them in a wheelchair than it is to encourage them to stand and slowly ambulate with their walker into the bathroom. It is easier to document that a patient refused to partake in PT than it is to coax them into participating. But the most exasperating problem was that the picture that PT documented did not accurately portray my father’s condition – and yet, that was what the insurer was going to rely on to make their coverage determination.

And, thus, eight days after transfer to the SNF, the social worker informed me that they expected his last covered day (LCD) to be three days hence. My father was nowhere near baseline – he couldn’t get out of the low recliner or the wheelchair by himself, and he wasn’t being assisted to go the bathroom unless I was there doing it myself. There was no chance he was going to be able to mount the three steps to come to my home for our weekly dinner. I couldn’t believe that this would be acceptable!

Alas, I had to accept the new reality – that my father had deteriorated significantly. He was debilitated and apathetic. I realized that he was not going to be able to return to his ALF, so I scrambled to find a memory care unit where he could get more attention and care – certainly more than he was getting in the SNF. I was lucky to find a caring, competent senior care placement professional who directed me to a small facility with compassionate staff, located close to my home. In a matter of just a few days, I made the arrangements and emptied his old apartment.

As anticipated, UnitedHealthcare (UHC) Medicare Advantage (MA) determined that his last covered day, Friday, would be the day I was flying to Spain for a long-awaited vacation. My brother was scheduled to come to daddy-sit on Sunday. UHC was going to kick him out on Saturday; the timing couldn’t have been worse!

The SNF social worker approached me with the Notice of Medicare Non-Coverage Form, otherwise known as the NOMNC, and informed me that I had the right to appeal this determination. The physician who was caring for my dad in the SNF disagreed with the determination and was willing to do a peer-to-peer (P2P). Unfortunately, the social worker who was managing my father’s case was apparently not well-versed in procedure, and was unaware that that the window of opportunity for a P2P was prior to the provision of the NOMNC.

The only recourse I had left was to contact the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) to file an appeal. The BFCC-QIO is comprised of healthcare providers under contract with the federal government tasked with monitoring and improving the quality of care given to Medicare enrollees. The QIO must be contacted by noon the day prior to the last covered day, so I called immediately upon receiving the NOMNC.

I spoke with a lovely representative from Livanta who painstakingly explained the process and registered my expedited appeal. She explained that the appeal would take up to three days (72 hours) to be decided. If an appeal is approved, then the MA plan pays for the stay. If there is an adverse determination, you have the option of a second appeal, which can take 10-21 days. You are responsible for the bill if the payer upholds the denial. The cost of a SNF can be in the $500/day range.

Thank goodness we had a favorable determination, so my brother was able to arrive and transition my dad to his new residence the next week. He is making strides there, because they aren’t reluctant to get him up and walking. The staff seems very congenial and caring. He’s adjusting well.

Why did I write on this topic? Here are the salient points:

  • Everyone should have an advocate when navigating the healthcare system. If you don’t know enough medicine, find someone in your familial, social, or professional circle who can advise you.
  • If your gut is telling you that your loved one isn’t getting the right care or treatment, trust your instincts and ask. Be persistent.
  • Take copious notes. When the doctor or nurse gives you information, it may be hard to remember. You may need to consult Dr. Google. Write it down: which doctor, what day, what time? Don’t be afraid to ask, “how do you spell that, please?”
  • As soon as a patient can move, they should, even if it is hard or painful. Mobilizing can be the difference between returning to prior life or being relegated to a nursing home – or worse. Deconditioning happens very quickly. It is a good idea to premedicate with pain medication in advance of physical therapy.
  • It is not your imagination that hospitals, SNFs, and other facilities are understaffed. And this is only going to get worse.
  • If you believe that your Medicare-covered loved one is being prematurely discharged from the hospital or SNF, you have the right to appeal. If the physician wants to try a peer-to-peer discussion, they need to do it before the NOMNC is delivered. Be sure you understand the process and the deadlines.
  • If you appeal a determination, talk to the physician or your friendly neighborhood case manager for persuasive verbiage. I called Ron Hirsch, and he told me to say my dad “still requires ongoing skilled care to return to his prior level of functioning.”
  • If you need to, find a senior care placement professional in your location. They can help you find competent assistance and/or a facility for your loved one. But do your own research, too. Check reviews and crowdsource on social media. It is reassuring for friends and acquaintances to confirm that their loved one had a good experience at that facility. Visit the facility and ask lots of questions.

It is heartbreaking to see your loved one lost to dementia. Adding the stress of poorly managed and executed medical care is overwhelming.

For those of you in my boat, I wish you smoother waters than I have had.

Programming note: Listen to Dr. Erica Remer every Tuesday morning as she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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