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CAN A PATIENT BE DENIED THERAPY SERVICES, IN A SKILLED NURSING
FACILITY, BECAUSE HE/SHE IS NOT MAKING PROGRESS?
This
denial may be blamed on medical judgment or Medicare rules.
If the
denial is based on medical judgment, the facility should be informed
that they are charged with trying to "maintain" a resident's
condition: "a facility must ensure that (a) resident's abilities
in activities of daily living do not diminish unless
circumstances of the individual's clinical condition demonstrate that
diminution was unavoidable."
Sec. 483.25(a)(l) of Title 42 of the Code of Federal
Regulations (emphasis added).
If a
denial is blamed on Medicare rules, there are two counterpoints to be
made:
-
Payment
source should not affect the care provided. Sec. 483.12(c)(l) of the Code of Federal Regulations.
-
Medicare
reimbursement does not necessarily require "progress".
The patient must need "skilled nursing services"
or "skilled re- habilitation services." Sec.
409.31-409.35 of Title 42 of the Code of Federal Regulations.
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