A very nice woman in a nursing home called our office to complete physical therapy following hip surgery. This individual was insured through Medicare after working all her life and retiring at age 70 because of a hip condition. She completed four weeks of physical therapy and was suddenly told by Medicare she was no longer progressing in physical therapy and her physical therapy was being terminated. This would result in the woman being discharged from the nursing home and sent home.
The woman contacted our office for assistance because she lived alone, had no family in the area, and believed she needed another two weeks of physical therapy before she could safely return to her home and live independently.
The Ombudsman met with the woman at the nursing home the next day and explained she could appeal Medicare’s unilateral termination of her physical therapy by immediately filing an appeal with “KEPRO,” a third-party Medicare Quality Improvement Organization that decides whether a Medicare recipient has been discharged from medical services too soon.
The woman was surprised to learn that all Medicare recipients have the right to appeal discharge from a hospital or nursing home if they believe the discharge is too soon. The appeal process can be as simple as contacting KEPRO by phone and explaining why you are appealing. The Ombudsman knew the woman had been provided appeal information from the nursing home when her services were terminated and asked if she would like assistance calling KEPRO and filing her appeal over the phone.
The woman asked for assistance and the Ombudsman explained that after they contacted KEPRO it would take 24-48 hours for a decision regarding her appeal, but she would continue with physical therapy while her appeal was being decided. The Ombudsman further explained Medicare would continue to pay for her services until the appeal was decided. If she won the appeal, the woman would be permitted a set period of time before her treatment was revaluated. If she lost the appeal she would have to pay for services privately or return home. A third option would have been to remain in the nursing home as a Medicaid recipient, but that would include a lengthy application process and was not a viable option for this individual.
The Ombudsman and woman then contacted KEPRO together and submitted an appeal over the phone. During the conversation they explained how the woman had improved during physical therapy but needed another two weeks of therapy to gain strength, improve her ability to use a walker and safely return home. The appeal conversation lasted approximately 10 minutes and the Ombudsman and woman were informed a decision would be made in approximately 24 hours.
The KEPRO representative stated they would review the woman’s medical records from the nursing home and take into account what was reported during the phone conversation. The following day KEPRO issued a decision and determined the woman’s physical therapy should be extended another 14 days, which meant she could remain in the nursing home and continue physical therapy for at least two more weeks.
The Ombudsman returned to meet with the woman approximately 10 days later and found she had made incredible progress. The woman was able to use a walker, move from her walker to a chair or bed, and was visibly stronger since their last meeting. The woman informed the Ombudsman she was much stronger and would be ready to return home in a few days.
The Ombudsman and woman then met with the social worker, the nursing home employee responsible for discharge planning, and made certain the woman would have all the services necessary to safely return home. The Ombudsman ensured the woman had home healthcare services during her first month home and that transportation was scheduled to take the woman to her doctor appointments. Additionally, the woman would continue with physical therapy at home and the Ombudsman confirmed the woman knew the days and times when the physical therapist would visit.
The woman has been home now several months and no longer requires physical therapy and is actively involved in her community. The woman was appreciative of the help provided by the Ombudsman and for having an advocate by her side.
THE OMBUDSMAN column, a production of the Joint Office of Citizens' Complaints, summarizes selected problems that citizens have had with government and social services, utilities, schools and nursing homes in the Dayton area. Contact the Ombudsman by writing to 11 West Monument Avenue, Suite 606, Dayton 45402, or telephone (937) 223-4613, or by electronic mail at firstname.lastname@example.org or our website at www.dayton-ombudsman.org.
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