As a Texas medical malpractice lawyer, I have handled many cases involving patients who received poor care at skilled nursing facilities (SNFs). From this experience, I have formed the opinion that this is partially because some administrators and health care providers seem to give their primary attention to Medicare qualification, rather than in delivering quality health care.
Skilled nursing facilities (also called SNFs) are facilities that provide rehabilitation care to Medicare beneficiaries. Most facilities are certified to provide care to both Medicaid and Medicare patients.
Leave it to the government—the rules for getting approval for skilled nursing facility admission are complex and burdensome.
How Medicare skilled nursing facility/SNF coverage works
Medicare Part A is the component that provides hospital insurance. Medicare Part A allows admission to a skilled nursing facility under strict conditions for a limited time period. For Medicare reimbursement purposes, a skilled nursing bed can be in a hospital or in a separate SNF.
These are the Medicare SNF admission requirements:
∙ You are enrolled in Medicare Part A and has days left in the benefit period.
∙ You have a qualifying hospital stay. This one is a bit tricky. The hospital stay must be a minimum of three inpatient days. Time spent in the emergency room or in an observation unit does not count toward three three-day threshold.
∙ Your doctor orders skilled nursing or therapy services for a hospital-related medical condition, or one that started while you were receiving SNF care for a hospital-related medical condition.
∙ Generally, you have to enter the SNF facility within 30 days of your hospital stay.
∙ The facility has to hold Medicare certification.
If you are admitted to a SNF for therapy, you have to participate in therapy, or Medicare may revoke the coverage.
Under original Medicare, the eligibility and costs are determined by benefit periods. A benefit period begins on the first day that you are admitted to a hospital or SNF, and ends when you have not received any hospital or SNF care for 60 days in a row. The concept of a benefit period was designed to provide coverage for an illness or spell that gets resolved.
If all the boxes are properly checked, Medicare will pay for up to 100 days of a SNF admission per benefit period. Beginning on day 21, though, a hefty co-pay (over $160 per day) kicks in that is the patient’s responsibility.
SNF peril #1: Premature hospital discharge to a SNF
I have frequently encountered situations where my clients were discharged way too quickly from a hospital, and sent to a skilled nursing facility with serious infections or other conditions.
SNFs provide a lower level of care than a regular hospital. In my experience, they may not be able to meet some patients’ needs, regardless of what they promise.
The time to raise your concerns is before discharge from the hospital.
SNF peril #2: Cutting benefits too early
Even though Medicare SNF coverage can last up to 100 days, the coverage ends as soon as the facility determines that the patient no longer needs skilled nursing care.
Some nursing homes will decide that further care is unneeded if the patient stops making progress toward recover. The correct standard, though, is that continued care is necessary if the patient requires it in order to maintain current functional status or to slow deterioration.
If this happens, the patient can go through a Medicare appeal process.
SNF peril #3: Quality of care varies depending on how far the clock has run
I have seen numerous cases where the mood of providers and administrators in a skilled nursing facility dramatically changes as a patient approaches the 20th day of Medicare SNF coverage.
While facilities are initially eager to qualify a patient and get them into the door, some of them become equally motivated to kick them to the street when the 100% payment by Medicare is about to end.
I have represented multiple clients who were told by SNFs that a patient needed no further care, despite the fact that the patient had deteriorated, had bedsores, respiratory, or other serious issues.
Just today, I met with a new client who told me that she had to call 911 to get help for her mother. Believe it or not, that is not the first or second time that I have been told this by a new client.
What you can do
I have to admit that, overall, I do not have much confidence in skilled nursing facilities.
If you have a loved one who needs SNF care, start by doing some research. Check out Medicare’s website, which allows you to compare different facilities. In addition, visit the potential facilities and bring along Medicare’s handy checklist, which you can download here.
In addition, I recommend that family members and friends split shifts to keep someone with the patient 24/7. In my experience, many SNFs are under-staffed and there are risks of medication errors an overall inattentiveness, even when something goes wrong.
We are here to help
If you or a loved one has been injured because of poor care at a skilled nursing facility, call Painter Law Firm for a free consultation with an experienced medical negligence lawyer. Our phone number is 281-580-8800.