Published in the July 25 – August 7, 2018 issue of Gilroy Life

James Ward

A recent story 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 because they don’t know the rules and aren’t aware of their rights. Make sure you learn the basics before you need to get care for someone, and make sure 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 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” 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 over-billing and improper evictions.

Why? The nursing homes can increase profits by violating the law, and most families never know they’ve been 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 bill 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 my client had died that morning.

When the family came to see me a week later, I found out they had been charged a little more than $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 advised them to go back and seek a refund.

A few weeks later the family was happy to advise me the nursing home had immediately given them back a little more than $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 letter asking for a written reply explaining exactly why the nursing home was not returning the entire amount to the family of the deceased.

After three letters from the family and still no response, the family phoned the nursing home and was told they could come in and discuss the issue. The nursing home cleverly never put anything in writing. They simply explained it was a billing error. They said 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 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.

James Ward

James Ward

Jim Ward is a longtime South Valley resident who resides in Morgan Hill. He went to law school in New England and obtained a post-graduate law degree in Estate Planning at the University of Miami. Jim worked as an Estate Planning and Elder Law attorney in Florida, and then returned home to open his law firm focusing on Estate Planning and Elder Law. He maintains offices in South Valley and another in Willow Glen.
James Ward