Problem:

Mrs. M spent six weeks recovering in a skilled nursing facility (SNF) after being in the hospital for a broken collarbone. Medicare covered the first month of her stay in the SNF, but not the last two weeks because it believed the care was no longer medically necessary. Mrs. M received bills for almost $5,000 from the SNF for the last two weeks of care.

What To Do:

Mrs. M read her Medicare Summary Notice (MSN) which stated that the SNF was responsible for the cost of the non-covered services. She called her State Health Insurance Assistance Program (SHIP) and asked about this note. The counselor explained that the patient is not responsible for payment for an inpatient stay if Medicare has determined the care given was not medically necessary and the SNF fails to give a patient an Advance Beneficiary Notice to let them know that Medicare may deny care. The SNF must absorb those costs. In Mrs. M’s case, Medicare determined that the SNF was liable because it did not inform Mrs. M that Medicare may not pay for the last two weeks of her care.

Mrs. M called the SNF and explained to them what the Medicare intermediary had told her. The SNF subsequently stopped billing Mrs. M and reimbursed her for the portion of the bill she had already paid.

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