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Medical Forum / Diseases and Disorders / Arthritis / August 2007

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otp: medicae issue--is there anyway to fight this? Long

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Diane - 02 Aug 2007 21:12 GMT
Back to my sister's roller coaster. You may recall she broke her hip
(and has severe MS). she's now in a rehab facility, which has been
rocky all on its own, but we thought we had the rocks sorted out. she
was just informed that if she is not weight bearing on at least one
leg, medicare won't cover PT, ie her rehab stay. It's her right hip
she broke and that was the one leg she could weight bear on, and of
course she can't bear weight on it now. she can stay until august
tenth when she sees her doc. if he says she can bear weight on it, she
can stay. (unlikely). if not, she goes home to die (her words). she's
not eligible for medicaid cause has too many assets, though certainly
not enough to pay for rehab herself. she has secondary insurance, but
it only pays after medicare.

this is all confusing to me at the moment, since i just heard from her
and she's very upset. she was working hard in PT on upper body
strength and just feels beaten down by this. I really don't understand
the frigging medicare rules. she has MS for pity's sake. who could
possibly need PT more?

on top of that, she's had a foley catheter in for 8 days (7 is the
limit). she usually catheterizes herself to urinate, but of course
can't do that now and is scared of infection. (UTI's are apparently
often the cause of death in MS patients).

thanks for letting me vent. if any of you have any experience with
this and know how i can help her fight it, please let me know.
meanwhile, i do think the SW and case manager at the rehab place are
doing their best.

diane
Ann Marie - 02 Aug 2007 21:39 GMT
I don't pretend to know a thing about Medicare except my friend's mom
broke her hip a few months ago while recovering from a stroke.  The
first rehab unit she was in left her in bed with no rehab for two weeks
and then said she would have to leave.  My friend called the omsbudman
for nursing home patients and got her transfered to another facility
where medicare paid for her P.T. for so many days.  The PT people there
exercised her in her bed and then in a chair for some time before they
got her up on her feet.  Maybe there are different rules in different
areas but I shouldn't think so with Medicare being a federal program.
Have you looked in www.medicare.gov. for info?

Ann
d'huit - 02 Aug 2007 21:56 GMT
her doctor needs to be informed of this right away.  doctors know what to
write on the medicare forms (and any kind of medical insurance forms) to get
their patients the care they really need.  she needs to put this in her
doctor's hands and have him/her follow up on it.  her doctor can make it
happen.

kate

Back to my sister's roller coaster. You may recall she broke her hip
(and has severe MS). she's now in a rehab facility, which has been
rocky all on its own, but we thought we had the rocks sorted out. she
was just informed that if she is not weight bearing on at least one
leg, medicare won't cover PT, ie her rehab stay. It's her right hip
she broke and that was the one leg she could weight bear on, and of
course she can't bear weight on it now. she can stay until august
tenth when she sees her doc. if he says she can bear weight on it, she
can stay. (unlikely). if not, she goes home to die (her words). she's
not eligible for medicaid cause has too many assets, though certainly
not enough to pay for rehab herself. she has secondary insurance, but
it only pays after medicare.

this is all confusing to me at the moment, since i just heard from her
and she's very upset. she was working hard in PT on upper body
strength and just feels beaten down by this. I really don't understand
the frigging medicare rules. she has MS for pity's sake. who could
possibly need PT more?

on top of that, she's had a foley catheter in for 8 days (7 is the
limit). she usually catheterizes herself to urinate, but of course
can't do that now and is scared of infection. (UTI's are apparently
often the cause of death in MS patients).

thanks for letting me vent. if any of you have any experience with
this and know how i can help her fight it, please let me know.
meanwhile, i do think the SW and case manager at the rehab place are
doing their best.

diane
Donna G. - 02 Aug 2007 23:23 GMT
Diane,

First of all, prayers to your sister, you & John, and all of those who
love your sister!

Don't you just friggin love the way these medical establishments jack
you around at your very worst time, health wise!  Grrrrrrrr, they should
all have to endure half of what they inflict on their patients.

I agree with Ann, check out the medicare site to see what they have to
say, but something just doesn't ring true about this.

Your sister definitely needs a social worker and case worker working on
her behalf, but also, when admitted to the hospital and facilities,
usually the patient is given a piece of paper that gives a number to
call for medicare if you feel your are being treated unfairly or
discharged too soon, etc.  This number is for medicare and they will do
a review of the case.  I think I would also call the patient relations
department of the facility, the CEO of the facility, get the doctors and
therapists involved, the social worker involved, call that number listed
by medicare to file a complaint, and also call the insurance ombudsman
for the state.  I would also even consider putting a call in to the
state representatives to help out in this matter!  In other words, now
is the time to make as much ruckus as possible over this situation with
as many people as possible.  Your sister does NOT need this added stress
on top of everything else she is dealing with, that's for sure!!!

Also, your sister needs to speak up and let them know that they need to
get that catheter out before she ends up with an infection.  Shoot, I
only had my cathetar is for 5 days after my stroke, before developing a
raging UTI where I was passing huge amounts of blood and clots, not to
mention the pain and fever that went with said infection.  Truly
miserable.  I was scared to death about getting the cathetar out,
because I couldn't do anything on my own, let alone have to get up and
go to the bathroom, but the rehab unit in the hospital put a bed side
commode about 5 inches from my bed and when I had to go, 3-4 people had
to get me out of the bed and turned around to sit on that commode.  It
was quite the production and quite exhausting at the beginning, but in a
way, it was its own form of therapy.

Anyways, sorry to get side tracked here.

Just tell your sister not to let them bully her and for her to make lots
and lots of noise to get the proper treatment she deserves!!!

Heck, this situation almost seems like it is discriminating against
someone with multiple handicaps!  Grrrrrrrr.......the local new channels
and news papers would have a field day with all of this nonsense!
.
.
.

Donna
.
.
.
.
1.   ANGELS EXIST, but some times, since they don't all have wings, we
call them FRIENDS......

2.    J.K.M.A.
Donna G. - 02 Aug 2007 23:26 GMT
BTW, Diane, when I was in the acute care rehab facility, there were
patients that were literally rolled down to PT in their beds and given
PT in their bed and then rolled back to their rooms.  Others were
strapped into a wheelchair and wheeled down to PT and given their PT
without ever leaving their chair.  Of course, the goal was to eventually
get them upright and weight bearing, but sometimes that takes a whole
lot of time to get to that point!!!

Donna
.
.
.
.
1.   ANGELS EXIST, but some times, since they don't all have wings, we
call them FRIENDS......

2.    J.K.M.A.
Diane - 02 Aug 2007 23:58 GMT
these replies are really helpful. i'm going to get on the phone
tomorrow and call EVERYONE. Joe I think the reason medicare would pay
for you was you had a weight bearing leg. this is so incredibly unfair
and you're right, donna, it does feel very discriminatory. my sister
feels like she's being tossed aside.

thanks,

diane
Fire Chief - 02 Aug 2007 23:27 GMT
> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
> rocky all on its own, but we thought we had the rocks sorted out. she
> was just informed that if she is not weight bearing on at least one
> leg, medicare won't cover PT, ie her rehab stay.

Your sister's problems may be with the type of rehab facillity.  Is it
a SNF?

Medicare has new rules this year.  Formerly it paid almost any/all PT.
Now it pays for PT in a "hospital environment", whatever that means.

Medicare paid for my PT and OT in the hospital following my surgery
last week, was going to pay for the rehab facility (part of the
hospital), and now is paying for at least 5 home calls by PT ordered
by the surgeon.
sweetpickleNO@SPAMknology.net - 03 Aug 2007 01:43 GMT
Diane, somebody needs to get her senator and/or representative working on
this for her.  Exceptions are made!
Gwen

> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
[quoted text clipped - 26 lines]
>
> diane
Kelly - 03 Aug 2007 06:58 GMT
http://www.drugs.com/cg/how-to-care-for-your-foley-catheter.html

Diane,
I am including the link to foley catheter  care.  I was told this was safe
as long as it remained a closed system and the above care was taken.  The
important thing is no tugging on the system and that it "dangles".  Cleaning
the areas concerned religiously.  Then it can stay in for longer (as a
matter of fact in some cases people definitely need it longer so there I
wasn't the only one.  In my case it was in for 7 days in the hospital and 5
weeks in total.  That was too long and I wasn't given instructions for care
until too late - by then I had an infection.  That would not happen in the
future.  I know Diane had one in for a bit but mainly they were depending on
depends for her not catheterizing.  Is there anyone who can catheterize her
there safely?   I know that is not usually an option.  Can her MS doctor
give her any help?  Any ideas?

If she had only one leg (ie an amputee) would weight bearing on her arms (ie
since her upper body is pretty darn good by the sounds of it right now)
would they let her continue with pt?  Could that be an option.  Basically
she is in that position.  This makes no sense to me - the idea is to rehab!
This is crazy.  Wish I knew the american system and could help you out.

I will keep her in my prayers and thoughts and am sending good vibes her
way.  She must be so frustrated and scared.  Wish I could help more.

hugs,
Kelly
> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
[quoted text clipped - 26 lines]
>
> diane
Kelly - 03 Aug 2007 07:03 GMT
http://www.medicareadvocacy.org/FAQ_RehabHosp.htm

Is this link of any help Diane??

Kelly

> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
[quoted text clipped - 26 lines]
>
> diane
Diane - 03 Aug 2007 16:02 GMT
kelly, thanks for that link. you're amazing!

we've got the phone lines heated up and i hope we're making some
progress. i'm so sick of our medical system. universal health care is
never going to happen here. will let you all know where this goes.
meanwhile, thanks so much for the ideas. they truly help.

kelly, she gets the foley out today. she is able to catheterize
herself and has for years, but it's all very difficult because they
need to use this "hoist" to move her around which makes it hard to get
her on a toilet. she can't easily catheterize herself on a bedpan,
though i guess the nurses will have to. i'm praying she doesn't get an
infection.

as for upper body strength, that's what they were/are working on right
now in rehab and she was working hard at it with her usual
determination, but now she feels so beaten down. she doesn't have good
control of her arms with the ms. amazingly, though, she could drive
her specialized van, using her right foot (the leg with the broken
hip), special brakes and specially sensitive steering.

hugs, diane
Kelly - 03 Aug 2007 16:28 GMT
So glad things are stirring up a little and hopefully the link will help.  I
am also glad for her the foley is coming out but like her I would be nervous
about the self cath done by the nurses - the good thing is she knows exactly
how to do it so she will be watching carefully and will make sure she gets
it done enough - that is probably the most important thing!  Tell her not to
prolong it longer than she normally would - that is so easily done if the
nurses are busy etc.  I can do it flat on myself but only if I have movement
in my hips and good hand control.  My monthly treatment that I use a
catheter with I am now going to a clinic for until the RA improves.  Is
frustrating as it is time booking the appointment, driving 1/2 hour, short
wait etc. all for a 5 min procedure.  March on rituxan.

If you think she would be okay with it I am sure there are several of us
that would send a card encouraging her!  I know she has her community but so
many of us have been in this up/down position.

You take care too.  Hopefully this will work out just great!

Kelly
> kelly, thanks for that link. you're amazing!
>
[quoted text clipped - 18 lines]
>
> hugs, diane
jofirey - 03 Aug 2007 18:43 GMT
I read an article in the Sacramento Bee over breakfast this morning.  Didn't
read it all but the gist of it was that a firm that has been handling
approvals for rehab for Medicare in California is being investigated for
massive rejecting of legitimate claims.  Apparently the more claims they
deny the more money they make?

Can't believe it would only happen in California.

It would make sense to me to deny rehab if someone did not have one weight
bearing leg "before" the incident or surgery in question.  Sort of.  But the
way they are interpreting this, if someone broke both legs in an accident
they wouldn't qualify for rehab, even if they had been and could be
perfectly able bodies.  She had one weight bearing leg to start with and
should have every right to get it back, or at least to have every one make
every effort to get it back.

Heck under their interpretation of the rules, if someone broke both legs,
they should be denied treatment altogether!

Jo
> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
[quoted text clipped - 26 lines]
>
> diane
Diane - 03 Aug 2007 23:11 GMT
i spoke with the social worker at the rehab center today. the "one
leg" thing is a bit misleading. medicare won't cover if you don't need
skilled nursing care (which includes rehab). there are specific
(ridiculous) definitions for what requires skilled nursing care, and
believe it or not, my sister doesn't meet any of them. (feeding tubes
etc). so medicare will now cover two weeks while PT works with her
(stretching, range of motion, etc), at which time the pt's will
reevaluate her and determine if they can help her even though she
can't bear weight. if so (apparently this is unlikely), they can make
a case to keep her on. if not, she will have to go somewhere until she
can bear weight (probably another 4 weeks--this was a break, not a
replacement). she can go home with a 24 hour STRONG person we'll have
to find and whom she'll have to pay for or she can stay where she is,
but she'll have to pay the $380/day out of pocket.
i feel clearer on the whole mess, even though it's still not a pretty
picture.

diane
Ann Marie - 04 Aug 2007 04:00 GMT
This makes more sense based on what my friend told me when I asked her
tonight about her mom's case. They removed her from the first rehab
place due to lack of care.  In the second rehab place Medicare paid for
21 days of PT (She broke her hip during her recovery from a stroke).  At
the end of the 21 days, they allowed her another 14 days because she was
showing improvement and the doctor felt she would be back to whatever
had been normal for her before the hip fracture with more PT than could
be supplied on an out-patient basis.  It depended on the doctor!!!
This whole thing is just horrible and I certainly hope it will turn out
well for your sister.

Ann
Squirrely - 04 Aug 2007 15:41 GMT
This is really ridiculous Diane, I can't believe they are doing this to your
sister. As if she isn't under enough stress just dealing with getting
better.

I don't understand the rules either. I thought that is what they were there
for was to give help to those that needed, not deny them treatment.

I hope she doesn't have any problems with the UTI's.

You and she are in my prayers.

Signature

Love and Hugs to all
Jo the squirrely one

> Back to my sister's roller coaster. You may recall she broke her hip
> (and has severe MS). she's now in a rehab facility, which has been
[quoted text clipped - 26 lines]
>
> diane
 
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