How Medicare Saves $$$ At The Expense of Patients Who Need Skilled Nursing Homes

This is a true story. My wife went into a Skilled Nursing Home for the Medicare allowed 90 days. She went in with and was discharged with a peg tube. This means all nutrition, hydration, and medication, must be given through the peg tube. She is not able to swallow.

She was home for 63 days and then needed to be hospitalized 8 days. Her doctor said she needed to be admitted to a Skilled Nursing Facility again. However, Medicare said she had used up all her days.

I did much research and found that if a patient uses up his/her 100 days, it starts all over if the patient is out of the hospital for 60 days and then is admitted again for 3 consecutive days.

I called Medicare and went up the Chain-of-Command as far as I could via phone. Each representative searched the rules and said he/she cannot understand why the computer states her days are used up, because it appears that, by their own rules, her time should start again. However, there is nothing they could do. because they must follow what the computer states. No one could explain why her 90 days did not start over.

Finally, I got an answer. Medicare said she left the SNF with a peg tube and that is considered skilled care even if she is at home. She would have to be off the peg tube for 60 days and then in a hospital for 3 consecutive days in order for her time to start over.

After much research at Medicare's site, I found that if a patient on a peg tube uses up his/her 90 days and then stays in the SNF (using personal funds, insurance, Medicaid, whatever), this is considered skilled nursing care. Nothing anywhere was said about being at home with a peg tube is skilled care.

I believe someone probably got a bonus for saving Medicare tons of money by interpreting the real policy to include staying at home.

I contacted my Senator's office in DC, and they gave me a phone number to call. I explained the situation to the woman on the phone, and she said she would look into it. She called the Medicare underwriter who said a peg tube at home is not considered skilled care.

Bottom line: The decision was reversed, and my wife got another 90 days. I wonder how many others were turned away for the same reason.