By: Dov Fischer
(Continued from last week)
If you timely appeal, the QIO then does a rapid review and usually decides by the next day whether to sustain the hospital discharge or to order an extension. Usually, the QIO backs the hospital, but sometimes they sustain the appeal. If they rule against you, you can ask them for a “reconsideration.” That buys another day or two. While the thing is under QIO review and reconsideration, Medicare pays for the extended hospital stay, so you usually can get at least one or two extra hospital days covered by Medicare just by appealing to the QIO. By law, a hospital cannot throw a patient out on the street if you refuse to accept the discharge; they must then continue to hold the patient. Once the appeals process is over, however, if you have lost and refuse to accept the discharge, then the patient or you will have to pay out of pocket for any additional hospital days, and that of course costs a fortune.
Most people do not know about the QIO stuff. By the time they figure it out, the 12 noon deadline has passed. Yet another bonus — even for the trolls — for being one of my regular readers.
Note: There are “Case Managers,” and there are “Case Managers.” Some can be incredibly helpful and deeply sensitive in matters other than discharge. Some will help you obtain esoteric medicines that are difficult to get at your local pharmacy. They will help you obtain “durable medical equipment” (see below) needed for use in your home. Even after the patient has been discharged and is at home, they will help make certain connections, obtain physicians’ signatures, and be really helpful. It will not take long for you to determine with which kind of “Case Manager” you are dealing.
- “Skilled Nursing Facility” Versus Home Caregivers
The elegant name for nursing homes and senior-care (“old age”) homes is “skilled nursing facility.” If you are admitting a loved one to such a facility, do your research on sites like “Yelp!,” etc. Remember, as with users’ reviews of everything, angry people are more prone to go online and tell the world about their mistreatment than happy people are to take out the time to post praises. So read the reviews with a discerning eye and ear. Typically, a nursing home has one staffer for every 15 patients. They have to make a living and a profit, and that is what it is. Remember that ratio: one per 15.
By contrast, in your home the person gets personalized attention and care. But it can be very demanding and draining. You may find you need to hire a caregiver or more. There are places on social media to find caregivers privately, and there also are agencies that provide caregivers. It is much less expensive to hire privately than through an agency. If you follow the law, you need to consider that caregivers must be in America legally, that FICA must be paid, state disability insurance, all the legal administrative and paperwork requirements when hiring a person legally.
If the caregiver gets hurt in your home, you or your home-insurance or umbrella policy may be liable unless they themselves are insured. If they are crooks, druggies, or other social lowlives, well — not good to have them in your home. Thus, getting your caregivers through an agency costs a bunch more, but you know the caregivers are here legally, have been vetted, are bonded, are insured, have been put through some caregiver training, are answerable to an employer, and that the agency takes care of the governmental payroll requirements.
Agencies have caregivers who are great and others who are crummy. It seems that they initially send the crummy ones, hoping somehow that the new client will not know what a good one is like, so will accept the crummy one who is hard for the agency to place with clients who know better. Usually, the first caregiver or two or three whom they send you are crummy. At that point, after a day or two, you call the agency and tell them that you will go to another agency — and you do your online homework, so you can name the other agency because that knowledge lets the first one know you mean business — and then they send a good one.
A good caregiver is a G-d-send. The problem then becomes that wage-hour law will require you to pay time-and-a-half (“overtime”) for any caregiving by that person exceeding eight hours daily or 40 hours a week. So, if you need eight hours daily for seven days a week, it will not suffice to maintain only one excellent caregiver, but you will need to get a second one also through the agency: one who comes eight hours daily four days per week, the other three days per week. Likewise, if you need more than eight hours daily, you similarly will need a separate nighttime caregiver because, if you use the day person for all 12 hours or whatever in the same day, you run into “time-and-a-half.”
The excellent caregiver will cry with tears that she really needs the added income from working 56 hours all week (seven days at eight hours daily), not just 32 hours, and you will cry with her that you wish she could be there all 56 hours. She even will volunteer to work the 56 hours and waive her rights to the overtime pay. But she voted Democrat, and now she can enjoy her “worker protections,” drinking her tears with a paper — not plastic — straw. If you try allowing her to waive her “time-and-a-half,” know that by law it cannot be waived, and she later can sue you for treble damages (not just what you underpaid, but three times that amount). And if she does not sue because she honors her promise, the government can sue.
Often it just is not possible to provide home caregiving. Perhaps the nearest family are far away. Perhaps the person needs to be in a 24-hour-care environment that also provides a social setting for interacting with others. Thus, nursing homes can be better than home caregiving in certain situations. Note, however, that a person is far more susceptible to suffering a bad fall in a facility because they have only one staffer for every 15 people, unlike the personal care at home. Moreover, diseases like the flu and pneumonia are far more prevalent in a “skilled nursing facility” than at home. Not to mention COVID-19 in Andrew Cuomo’s New York and in other such states that adopted policies similar to his.
- Physical Therapy, Occupational Therapy, Speech Language Pathology
A Physical Therapist helps rebuild a person’s body from the waist down (e.g., strengthening the legs, regaining standing and walking skills). An Occupational Therapist helps rebuild from the neck down to the waist (e.g., arm strengthening, self-grooming like brushing teeth and washing one’s face, dressing oneself), and a Speech Language Pathologist helps rebuild from the neck up (e.g., cognition and memory skills, swallowing, focus and attention). Thus, an Occupational Therapist has nothing to with a job or occupation, and a Speech Language Pathologist often has very little to do with speaking or language (although, if a person does have speech impairment, that is within the rubric of the Speech Language Pathologist).
After a hospital stay of at least three overnights, Medicare and most private insurances will pay for a few weeks of home health services that include some visits of a Physical Therapist, Occupational Therapist, and Speech Language Pathologist, as well as a home nurse. That coverage typically runs three or four weeks. After that, Medicare and many private insurances will cover additional weeks of ongoing Physical Therapy and some Occupational Therapy at an outside facility. In this coronavirus era, it is important to select a top-flight facility that seems to be really proactive on taking prophylactic steps to protect patients from contracting COVID.
- Transportation to Medical Appointments and Home Blood Draws
Some patients are less ambulatory than are others. Yet sometimes even an incapacitated patient needs to travel — say for a medical diagnostic test like a CT scan or MRI, or for an in-person doctor’s appointment that cannot be conducted via a Tele-Med or Zoom-type session. For these patients, there are private companies with wheelchair-friendly vans and others that even transport people on gurneys as do ambulances. These options exist but can be very expensive. Often, if a doctor like a primary care physician or the doctor who is being visited for the appointment certifies that the patient physically cannot get to the diagnostic test unless by special transportation, that private transport will be covered, in whole or in part, by private health insurance.
Similarly, especially in the current coronavirus environment, there are companies that come to your home to draw blood when needed for laboratory tests. These often may be covered by Medicare or private insurance with proper medical-need certification.
I hope this information is helpful, and I hope you will not need this for a long time and just will file it away for now. Part Two will include additional information along these same lines, including what you may find helpful to know about obtaining necessary in-home durable medical equipment, stairlifts, contemplating wills and advance directives, and dealing with mortuaries and cemeteries.
