The experience of a hospital physical therapist dealing with Medicare Advantage plans

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I have worked as an inpatient physical therapist for many years. My main role is to assess patients and their possible rehabilitation needs in preparation for hospital discharge.

In the past I didn’t have to know exactly what kind of insurance a senior citizen or disabled patient had in considering post-acute rehab needs. Most had traditional Medicare. That has all changed in past five-plus years with the rising influence of Medicare Advantage (“A Minnesota health care battle royale,” editorial, Aug. 18, and other coverage).

I have had to understand some of the algorithms used by insurers to deny transitional care (nursing-home-based) rehab as well as acute-care rehab (hospital-based inpatient rehabs).

Medicare Advantage allows seniors to choose to receive their government-sponsored health care benefits through a private managed care insurer. Some Medicare Advantage plans seem to follow Medicare guidelines for admission to skilled nursing or acute rehab and others do not. The most problematic Medicare Advantage insurers have been UnitedHealth, Humana, Aetna and Cigna.

My patients were getting denied transitional care rehab for one reason and one reason only — the ability to walk 75 feet and the level of assistance needed for that. If patients required some supervision close by and walked 75 feet, they would be denied. It did not matter if they needed the assist of one person to stand or the assist of one person to get out of bed. There were other factors that did not matter: a patient’s cognition or how much support they had at home or whether they had stairs to negotiate.

Furthermore, these companies did not consider the recommendations made by Occupational Therapy (OT): activities of daily living, toileting, dressing. All these metrics fall under Medicare guidelines for appropriate admission to post-acute rehab settings.

These companies do not take into consideration the nuances of many other issues contributing to a safe discharge home. Some patients do end up going home when it is not safe to do so in our professional opinion and end up back in the hospital.

For example, I recently had a patient with Humana Medicare Advantage who lived alone in an apartment with a couple of stairs but was blind and worked a few hours a week. They were functioning very well in the community. They used a white cane. When I met with them, I knew I just had to get them up and moving and stronger. They were too weak to use just the white cane and needed assistance to get out of bed. It was very difficult for them to stand from a seated position and balance. I decided to use a walker to just get up them and moving and guided them down the hall because of the blindness. We went about 125 feet. Not strong enough to even attempt stairs.

Medically they were ready to discharge from the hospital, and transitional care was the most appropriate setting. Humana denied the transitional-care stay because we had walked more than 75 feet with a walker, even I thoroughly documented that the patient could not function with a walker due to blindness and had excellent potential to return to prior level of function with post-acute rehab. OT also reported the patient’s inability to complete activities of daily living. Multiple appeals over days were also denied. These insurers failed to be compliant with basic Medicare guidelines and they got away with it.

Many times, I have met with patients and families who have just found out post-acute care has been denied, and it leaves them with anger, frustration and panic. Care managers work and physicians work tirelessly for appeals and the best discharge options. Many people end up staying in the hospital far too long, further risking infection or complications until a home discharge can safely occur or a denial gets overturned. This makes clearing hospital beds for backlogged emergency rooms filled with patients waiting for beds. The hospital basically eats the cost of a longer hospital stay because the insurers pay a one lump sum based on predicted length of stay for a particular illness.

I am now always mindful of their payor source every time I assess a patient.

Let us work to improve the affordability of Medicare supplemental plans, eliminate the three-day hospital rule, rein in prescription costs, etc. We need Congress to look closely at these companies’ practices. Our fellow citizens deserve better.

Sarah ten Bensel, of Minneapolis, is a physical therapist.