Improper Nursing Home Charges

A recent article in the New York Times stated, “We have a big problem paying for long-term care in this country, although most people don’t wake up to the challenge until it affects their family directly.”

Many families overpay simply because they don’t know the rules and aren’t aware of their rights. Don’t let that happen in your family. Make sure that you learn the basics before you need to get care for someone, and make sure that your legal documents will allow the individuals you trust to make the right decisions for you.

There’s a lot of confusion on when Medicare will pay for a skilled nursing facility. A Federal court case in early 2013 clarified that the nationwide standard applying Medicare benefits for long-term care in skilled nursing facilities was incorrect. The old rule-of-thumb standard was the “Improvement Standard” that resulted in many seniors being inappropriately denied Medicare coverage for something that should have been covered by Medicare. Now, more than five years after that court decision, many nursing homes are still misapplying the standard and denying Medicare benefits to residents.

Despite the court decisions, we still regularly see nursing homes acting in violation of the law with overbilling and improper evictions. Why? The nursing homes can increase their profits by violating the law, and most families never know that they’ve been scammed into making unnecessary payments. The insurance companies go along with this too because it saves them billions of dollars annually when they don’t have to pay the residents’ portion of the nursing home bill that Medicare doesn’t cover.

Most nursing homes follow the law, or can be nudged to follow the law, but some nursing homes act aggressively with false billing and improper evictions.

I was recently preparing to sign documents at a nursing home in the late afternoon, and then the family called to advise me that my client had died that morning. When the family came to see me a week later, I found out that they had been charged a little over $10,000 at the beginning of the month. I couldn’t understand why the family had been charged when the elder was still covered by Medicare. I thought it was wrong, and I advised them to go back and seek a refund.

A few weeks later the family was happy to advise me that the nursing home had immediately given them back a little over $6,000. Wow! … That’s great, but what about the remaining $4,000? Why wasn’t that returned?

I told the family to send the nursing home a signed letter and ask for a written reply from the nursing home explaining exactly why the nursing home was keeping the $4,000 amount and not returning the entire amount to the family of the deceased person.

After three letters from the family and still no response, the family phoned the nursing home and was told that they could come in and discuss the issue. The nursing home cleverly never put anything in writing. They simply explained that it was a billing error. They said that the deceased woman should have been kept on Medicare, but it was now too late.

That’s wrong in many ways. The nursing home could have returned the improperly charged amount to the family, and the nursing home could have corrected their error with Medicare. The more likely scenario, however, is that Medicare paid the nursing home and the nursing home also kept the family’s money. That’s double dipping. It’s called fraud.

Learn how things work. Don’t allow the nursing home to charge for something the elder is already entitled to under Medicare benefits.


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