Dear Mr. Miller:
My Dad is in a nursing home. He has $5000 in monthly income. The nursing home is costing $6000 per month. He has qualified for Medi-Cal and they are paying the shortage of $1000 each month. I hold his power of attorney, both for finances and health care.
Problem is, Dad’s physical therapy stopped last month when Medicare terminated its payment. I think Dad needs continuing physical therapy and that this service can help him. I’ve checked and it would cost about $1400 per month. I have spoken with the facility physician but he refuses to prescribe it. I’m unhappy with this physician anyway as he seems to spend virtually no time with my Dad. I think the medical care is just woefully poor. When I pushed the physician, he told us there would be no way to pay for this, anyway.
Obviously, if I have to pay for it out of my pocket, this will put a lot of stress on my family budget. But I want to do what is right for my Dad. What can I do? (back to top)
Trying to Do the Right Thing Daughter
Knowing Medi-Cal Rules is an Advantage: Medi-Cal is a maze of rules and procedures. It is no wonder that many facilities and physicians who deal with Medi-Cal do not know all of its ins and outs. That is where you (or your well informed Medi-Cal attorney) come in. In other words, once you know the basic rules you can educate the facility (and the physician) and have a much better chance of getting the best treatment for your Dad. (back to top)
Reducing Medi-Cal Share of Cost: In your case, here’s how the problem can be solved. In general, and subject to a few rules and procedures that we will discuss in a moment, one can deduct from Medi-Cal share of cost the expenses of non-covered services. So you can go out and hire a physical therapist and deduct his cost from the Medi-Cal share of cost you are paying the facility. Here’s the simple math: from the $5000 you pay the facility each month, simply deduct the therapist’s expenses of $1400 and pay the facility the difference. Give them the copies of the invoices from the therapist. You pay the therapist that $1400 you withheld from the facility. So the facility gets paid by you $3600 ($1400 short of what they think they are owed), the therapist gets paid his $1400, and you come out exactly the same. (back to top)
Johnson v Rank: Of course, the facility is going to be wondering from where their other $1400 is paid. You (or your attorney) will need to educate them on the Johnson v Rank regulations. Under these regs, they need to complete certain forms and submit them to Medi-Cal so they can be paid. (back to top)
Preliminary Steps: Note, that in order to follow the Johnson v Rank procedure, you will first need to have (1) the therapist’s services prescribed by the physician, (2) that prescription entered in your Dad’s physician’s “Plan of Care,” and (3) the physician’s prescription or order included in the medical records at the facility. It is only after this is done that you should hire the therapist. (back to top)
Replacing the Physician: And this brings us to problem number 2-the uncooperative physician. Apparently, the attending physician for your Dad is the one who does substantial business for the residents of the facility (i.e. “The house doc”). As with anything else, some house docs are great, others not so much. What most people don’t know is that, just like any other vendor, he can be replaced. The first course of action is to inform the physician to focus on the clinical issues and not to be concerned about payment. Just so you know, it is illegal to base treatment on the form of payment. (back to top)
If the physician is still uncooperative, just fire him and replace him with a physician of your choice. You have a right to do this under Federal Law. There are a number of benefits that could result from replacing the house doc with a more cooperative care provider. First, and foremost, is that this replacement will often result in a better plan of care. Further, it could result in continuation of wrongfully discontinued therapy. And lastly, but certainly not least, it could prevent premature discharges. (back to top)
Residents Have Rights: The moral of the story is, as a resident of a skilled nursing facility, your Dad has rights. If something does not seem to be going your way, consult an attorney well versed in Medi-Cal. (back to top)
Dec. 25, 2015