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Thread: How can I get my dad transported to his home state?

  1. #21
    We have pretty much given up on Shepherd. We tried all week to get them to admit him. When we pushed for specifics we were told that he is twice the age of the average person they see. When we asked if this was the reason for denial, we were told that they look at other factors as well. Our head hurts from hitting that brick wall.
    We are looking at other Centers in Georgia ( around the Atlanta area).

  2. #22
    Basically they told you it was because of his age then. But told you the roundabout way. Sorry to say at his age it will be a miracle if any acute care rehab facility accepts him. You may be better off looking at long term care places in atlanta.
    T6 Incomplete due to a Spinal cord infarction July 2009

  3. #23
    You also need to have a second option in Georgia ready to give the Social Worker if Shepherd won't accept him. After looking at the total picture and his health status, they may prefer that he go to a long term acute rehabilitation first.
    CWO

  4. #24
    I would still keep calling Shepherd. Have you gone as high as you can?

    I guess the way I look at it is .... this is not the time to be nice. This is not the time to accept no for an answer. Tell them that just because their average age of admitted patient is low (of course..... most traumatic SCI happen to young men), this is not a reason to deny care. Tell them you know they have accepted other patients with his level of injury, with similar medical history (he only has hypertension!) and similar current health in the past. Remember, the people you are pushing now are not the people who actually would treat your Dad. They are mostly administrators who don't even see patients, and are just thinking about numbers/money.

    I'm assuming he is medically doing ok now, outside of the spinal cord injury?

    Nurses, are they allowed to deny entry for someone with this level of injury based on age?

    Honestly, part of me thinks that it is against Medicare guidelines to refuse to treat someone due to age.... if he is similar to others in his current deficits/abilities who have been accepted in the past. They are probably being careful not to say it is based on age alone, but it is hard for me to believe this is allowed.

    Is he regaining any movement/sensation at all? There may be changes over time, so keep looking/asking. Has Shepherd said if they would reconsider if he improves at all? Have they recommended other local subacute rehab facilities for you to check with?

  5. #25
    Shephard Center is CARF accredited as a Spinal Cord System of Care (SCSC). I don't believe that CARF would consider refusal based only on age a legitimate reason. You could call CARF to find out (www.CARF.org).

    Have you contacted the Christopher Reeve Foundation Help Line? www.paralysis.org

    (KLD)

  6. #26
    Thank you all so much for your on point responses. They have been a tremendous help to myself, my mom, and my siblings...and ultimately to my dad. My dad was accepted at an LTAC in Georgia only to have Medicare refuse to pay stating that this was an "inappropriate level of care." I have reached out to various advocacy groups in Connecticut that focus on health disparities. We are appealing this decision.
    We have not given up on Shepherd. The hospital physiatrist is checking with his contacts to see if we can get our feet further in the door. We continue to be blessed with my dad's presence...his smile, his sometimes successful attempts to communicate his own thoughts by mouthing words. His first sentence - "I want food."

  7. #27
    Elegrier-

    Here's information about how to appeal an adverse Medicare decision. Keep pushing.

    http://www.medicare.gov/claims-and-a...e-appeals.html

  8. #28
    The LTAC wants him to go to SNF? or what? Not sure why they would say that. You need to find one with a ventilator and rehabilitation program. Acute rehabilitation like Shepherd requires 3 hours of therapy-total- a day. Medicare requires this also. They do have a special vent program but they have a waiting list and prioritize admissions. They look at many factors and age and average length of life. I have never known them to take an 80 year old.
    But don't give up hope- just keep looking and you will find a good place close to his home.
    CWO

  9. #29
    Good for you.

    Wow - Medicare even said he shouldn't be in LTAC!?!? This is more evidence he needs to be in acute rehab like Shephard.

    How great you are reaching out to groups that can help you advocate. Call everyone/anyone... Did you try calling the Christopher Reeve foundation? I like the Nurse KLDs reference for CARF. Call them. Shephard does not want its accreditation to be stained by refusing a patient like your Dad. And then you let Shephard know that you have talked with these places.... or even better... see if they can call Shephard or advocate in any way.

    It is so wonderful your father still has good spirits. Thank you for doing what you are to support him.

    While you are in this transition period, remember that your father's enemies will be the early "complications" of spinal cord injury that affect many of us who cannot move/advocate for ourselves.

    It is most critical that he is being turned regularly so that he doesn't get pressure sores (should be at least every 4 hours, turned from side to side and propped up with pillows), and that his skin (especially sacral area above the butt) is checked multiple times a day. It is hard to get assistance from the nurses/nurse's aids to do this, so sometimes it is helpful for you guys to remind them and assist (carefully). He also should have special boots on his feet to protect his heels and ankles from developing pressure sores... I cannot emphasize enough how important this is.

    Also, he is at risk for developing a blood clot (especially in the legs), so ask how they are trying to prevent this..... which is tricky because he had a bleed that caused his injury. At a minimum he should have boots on his legs that pump air in and out that help his circulation. Once they are less worried that he will bleed again, he may be put on a low dose of a blood thinner to prevent blood clots. Ask about this.

    He is at high risk for infections, as hospitals are dirty places... Make sure everyone (especially all hospital providers) wash their hands before they touch him. He is at high risk for urinary tract infections from the catheter, and pneumonias. Ask the respiratory therapists what advice they can give to prevent pneumonias. If he can ever get to sit up, this will help a lot.

    How great you have a physiatrist now helping you. Learn from this doctor these spinal cord injury complications that you should be watching for, and get his/her advice if they seem knowledgeable about SCI. Look at the links at the top of this forum (stickies) - especially those from the Paralyzed Veterans from America and the Christopher Reeve Foundation.

    Keep pushing....

  10. #30
    The initial denial likely came from the Medicare Administrative Contractor, (A.K.A "The MAC" ) with jurisdiction over your geographic area. Claims reviewers at this level have varying degrees of medical qualification and do not necessarily have to be specialists in the type of injury affecting your Dad. The percentage of claims denied at this level is high.

    Insist that your appeal get reviewed by a QUALIFIED medical specialist with direct knowledge of high level SCI patients.

    Here's a table of how the "game" is played. Knowledge is power. Best of luck to you. This Monday is a holiday so you will have to wait until Tuesday to call.

    [TABLE="width: 691"]
    [TR="bgcolor: transparent"]
    [TD="width: 691, bgcolor: transparent, colspan: 6"]

    MEDICARE APPEALS PROCESS
    [/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]
    Level of Appeal
    [/TD]
    [TD="width: 84, bgcolor: transparent"]
    Decision Maker
    [/TD]
    [TD="width: 138, bgcolor: transparent"]
    Individuals or Entities
    Authorized to Appeal
    [/TD]
    [TD="width: 126, bgcolor: transparent"]
    Timeframe to Request
    [/TD]
    [TD="width: 90, bgcolor: transparent"]
    Format of Request
    [/TD]
    [TD="width: 162, bgcolor: transparent"]
    Timeframe for Decision
    [/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]Level One—Redetermination[/TD]
    [TD="width: 84, bgcolor: transparent"]A/BMAC[/TD]
    [TD="width: 138, bgcolor: transparent"]A provider, supplier, beneficiary, other party, or a representative of the above[/TD]
    [TD="width: 126, bgcolor: transparent"]Within 120 calendar days from date of notice of initial or revised determination[/TD]
    [TD="width: 90, bgcolor: transparent"]CMS Form 20027[/TD]
    [TD="width: 162, bgcolor: transparent"]Within (w/n) 60 calendar days, with 14-day extension if additional information is submitted[/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]Level Two—Reconsideration[/TD]
    [TD="width: 84, bgcolor: transparent"]QIC[/TD]
    [TD="width: 138, bgcolor: transparent"]A provider, supplier, beneficiary, other party, or a representative of the above[/TD]
    [TD="width: 126, bgcolor: transparent"]Within 180 calendar days from date of notice of redetermination decision[/TD]
    [TD="width: 90, bgcolor: transparent"]CMS Form 20033[/TD]
    [TD="width: 162, bgcolor: transparent"]W/n 60 calendars days; if QIC fails to make its decision timely, provider may request escalation, which may occur if QIC fails to make their decision w/n 5 days of request[/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]Level Three—Administrative Law Judge (ALJ) Hearing[/TD]
    [TD="width: 84, bgcolor: transparent"]ALJ[/TD]
    [TD="width: 138, bgcolor: transparent"]A provider, supplier, beneficiary, other party, or a representative of the above, so long as amount in controversy threshold is met ($140), and CMS[/TD]
    [TD="width: 126, bgcolor: transparent"]Within 60 calendar days from date of notice of reconsideration decision; provider must notify all parties to the QIC reconsideration of the hearing request[/TD]
    [TD="width: 90, bgcolor: transparent"]CMS Form 20034[/TD]
    [TD="width: 162, bgcolor: transparent"]W/n 90 calendar days; if ALJ fails to make their decision timely, provider may request escalation, which will occur if ALJ fails to make its decision w/n five days of request[/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]Fourth Level—Appeals Council Review[/TD]
    [TD="width: 84, bgcolor: transparent"]Appeals Council[/TD]
    [TD="width: 138, bgcolor: transparent"]Any party not satisfied with ALJ’s decision, including CMS[/TD]
    [TD="width: 126, bgcolor: transparent"]Within 60 days of notice of ALJ’s decision
    [/TD]
    [TD="width: 90, bgcolor: transparent"]DAB Form 101[/TD]
    [TD="width: 162, bgcolor: transparent"]W/n 90 calendar days; if AC fails to make its decision timely, provider may request escalation, which will occur if AC fails to make its decision w/n five days of request[/TD]
    [/TR]
    [TR="bgcolor: transparent"]
    [TD="width: 91, bgcolor: transparent"]Fifth Level—Judicial (Federal District Court) Review[/TD]
    [TD="width: 84, bgcolor: transparent"]Federal District Court[/TD]
    [TD="width: 138, bgcolor: transparent"]Any party, if amount in controversy ($1430) is met[/TD]
    [TD="width: 126, bgcolor: transparent"]Within 60 days of notice of AC decision[/TD]
    [TD="width: 90, bgcolor: transparent"]Request must follow Federal and local rules for federal district court[/TD]
    [TD="width: 162, bgcolor: transparent"]Court follows Federal Rules of Civil Procedure and local rules for federal district court[/TD]
    [/TR]
    [/TABLE]

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