Long Term Care Hospitals (LTCHs) provide care to patients with medically complex problems. These complex diagnoses include, but are not limited to – Traumatic Brain Injury, conditions requiring prolonged mechanical ventilation, paralysis, very significant wound care, and other conditions resulting in organ failure – resulting in the patient requiring a hospital-level of care for an extended period.
To qualify as a Long-Term Care Hospital for Medicare payment, a facility must meet Medicare’s conditions of participation for acute care hospitals and have an average length of stay greater than 25 days for its Medicare patients. Medicare is a major payer for most LTCHs, accounting for about two-thirds of LTCH discharges.
Medicare claims for Long-Term Care Hospital care are suitable for Medicare coverage, and for appeal if they have been denied, if they meet the following criteria:
- The patient’s physician ordered an inpatient hospitalization for treatment of the patient's condition.
- The hospital (or a unit within the hospital) meets Medicare guidelines to qualify as a Long-Term Care Hospital.
- The individual requires treatment for a medically complex condition that can only be provided in a hospital setting. Additionally, the patient requires a longer length-of-stay for treatment – usually greater than 25-days – as well as programs of care provided by the Long-Term Care Hospital, including, but not limited to, comprehensive rehabilitation, respiratory therapy, and pain or wound management (although this is not an all-inclusive list).
- Long-Term Care Hospital stays count towards the beneficiary’s Part A inpatient hospital stay allotment per benefit period. Each Medicare beneficiary is eligible for up to 90-days of hospital coverage per benefit period, with an additional “lifetime reserve” of 60-days. A benefit period begins on the first day a beneficiary is admitted to the hospital and does not end until the beneficiary has not received a hospital or skilled nursing facility level of care for 60 consecutive days.
- It will be helpful to succeed on appeal if the patient requires close medical supervision (such as 24-hour availability of a physician).
- The opinion and active support of the patient's attending physician are key to obtaining coverage. If the physician believes that the patient’s care was medically necessary ask him or her to write a statement explaining with as much detail as possible why the LTCH care was medically necessary and that the needed care was not actually available in a skilled nursing facility or other level-of-care.
- Many patients, but not all, enter Long-Term Care Hospitals from an Intensive Care Unit (ICUs) or other acute care setting; this is not always the case and is not a requirement for Medicare coverage. After October 1, 2015, however, Long-Term Care Hospitals will be paid less for patients who have not had an ICU stay prior to admission. This may create difficulties for such patients to gain access to necessary LTCH care.
- Appeal as quickly as possible. In most cases the patient is entitled to an "Expedited Review,” which may provide for additional time in the LTCH before charges accrue, if the patient requests a review immediately.
- The Medicare denial notice given by the LTCH will tell you how to immediately appeal by contacting the Beneficiary Family Care-Centered Quality Improvement Organization. In Connecticut the telephone number is 866-815-5440.
- Don't be satisfied with a Medicare determination unreasonably limiting coverage and don't allow the patient to forego medically necessary care.
Appeal for the Medicare coverage the patient deserves.