Over the next few months, you may be hearing a lot about the CARES Act introduced in U.S. House of Representatives by an Ohio Republican. Unlike most issues percolating in our nation’s capital, the issues central to this bill are likely to receive bipartisan support as well as bipartisan opposition.
This is because two extremely large and powerful industries are at odds, and the results of their mutual lobbying efforts will have a great impact on the lives of seniors and their families.
One of the most critical issues in this case is a little known loophole in the way that Medicare contributes to nursing home care.
Here’s how the system is supposed to work:
A person on Medicare experiences some kind of traumatic health incident. That can be anything that results in a hospital stay. The person’s doctor admits him/her to the hospital as an inpatient. After three days in the hospital, this person is healthy enough to leave the hospital, but not well enough to return home.
The resident is then admitted to a nursing home/rehab facility to finish recovering. For the first 20 days Medicare will pay for the total amount of nursing home care. For the next 80 days, Medicare will pay for care, but require a $120/day copay (In many states, daily care averages between $150 – $400). After 100 days, Medicare will no longer pay for any long term care.
Here’s where the situation gets tricky. Medicare will only pay if the resident has been a hospital inpatient for three days (two midnights). If the patient was admitted to the hospital for “observation” instead of as an “inpatient”, Medicare will pay nothing.
That can easily result in a nursing home bill of tens of thousands of dollars.
The current flawed situation is a result of hospitals abusing the “inpatient” designation in past years. Recently, the Centers for Medicare and Medicaid have been imposing fines for improperly admitting seniors. As a result, hospitals are cutting back on “inpatient” statuses.
The CARES act seeks to remove the hospital from the equation entirely. Nursing homes with high standing in Medicare assessments will be able to admit residents directly.
Hospitals don’t like the idea of losing so many patients directly to nursing homes, and nursing homes like the idea of having Medicare pay for the short term stays that many nursing home residents need.
As a nursing home lawyer, I’ve seen a tremendous amount of nursing home neglect take place in nursing homes with sterling reputations from the Centers for Medicare and Medicaid. I’m not certain that nursing home staff will admit residents properly. It’s easy to imagine nursing homes admitting residents who should rightfully be in a hospital.
Even without the CARES Act, many nursing home residents suffer from nursing home falls, infections, and bed sores that should be treated in a hospital. Nursing home residents frequently are the victims of a wrongful death as a result.