Re: Break in Skill

[NJMDSRN]

I have been so busy that I have been unable to read the listserve, but I have to respond. Who is requesting the demand bill? Only the patient of the patient's representative can do that. Skilled care is skilled care and there should not be any additional Medicare time for this person. If the family wanted a demand bill that is fine, and the FI should deny payment because Medicare already paid for 100 days as specified by law. The family could appeal to an Administrative Law Judge, and it is possible that he/she would grant payment, as the ALJ does not always understand the technical and legal requirement of coverage. I know that there have been cases where ALJ's have approved payment for items excluded by statute in the past (when I worked for the local FI) and it creates major payment problems for the FI. But, again, if the provider knows that Medicare should not be billed, and bills anyway, that could be interpreted as Medicare fraud. When checking with the FI the provider needs to be honest and up-front with the information they present; information should not be selected to only show a favorable decision in the provider's eyes.   Sorry about the soap box. The requirements of the law and the best interests of the patient are often at odds, but we need to not "bend the rules" even if it favors the patient, as that is not seen in a favorable light by the $$ watchers in the government.   Karen Berry, RN MDS Coordinator County Manor Rehab & Healthcare Center 133 County Road Tenafly, NJ 07670 201 567 7800 email [EMAIL PROTECTED]