Nursing homes in America are fraught with problems ranging from abuse and neglect to sanitary shortfalls and fire hazards. As if these weren’t enough, another problem that care facility residents and their families must be concerned with is inaccurate billing and overcharging.
If you suspect these practices are taking place or feel that the care facility is not forthcoming about their billing practices, you should be concerned. Nursing homes can often get away with dishonest billing practices because of lack of oversight, that billing practices, in general, can be confusing to residents and their family members, and that sometimes people simply accept the bill without assessing it for accuracy.
The Cost of Nursing Home Care
Nursing home care in the United States is prohibitive for many only due to cost, which varies widely between different regions and states. Costs range from around $5,000 per month up to an astounding $25,000 per month.
Nursing home charges depend on its:
- Geographic location
- Staffing levels
- The complexity of care offered
- Size and quality
Some care facilities may offer à la carte services. For example, a care facility that offers financial management assistance may charge extra for that service.
Despite high nursing home care costs, don’t bargain hunt for a home for your loved one. You get what you pay for can apply in the nursing home industry. Many times, less expensive care facilities lack quality care and medical treatment. However, you do want the nursing home to bill your loved one correctly. It is your loved one’s right to know what their bill is for and how much those charges are.
Before admitting your loved one to a care facility, you may want to ask the following questions to understand the financial aspects of their services better:
- Is the fee structure easy to understand?
- What are the billing, payment, and credit policies?
- Are there different charges for various levels or categories of services?
- Are the billing and accounting procedures easy to understand?
- Does the care facility explain what services it covers in the quoted fee and what services are additional?
- What governmental financing options does the facility accept (Medicare, Medicaid, Medicare Supplemental Insurance, Supplemental Security Income, and others)?
- When may a contract be terminated? What is the refund policy?
Medicare Charges for Care Not Necessary or Never Received
With nearly 70 percent of all American nursing homes being for-profit entities, it’s common to see their profits over patients’ mentality.
- In November 2012, reports by federal health care inspectors from the U.S. Department of Health and Human Services revealed that each year the nursing care facility industry over-bills Medicare by $1.5 billion for medical treatments that residents either didn’t receive or never needed to begin with.
- In 2011, Medicare paid almost $32 billion on skilled nursing facility care.
- In the same year, 70 new nursing care facilities started participating in the Medicare program, and nearly all of them were for-profit care facilities.
How Medicare Coverage Works in Care Facilities
Most residents in a care facility will pay out of their own pockets for care until they are eligible for Medicaid. Since Medicaid is a type of welfare or is rooted in welfare standards, you must become “impoverished” under its guidelines to qualify. In some cases, they can use Medicare and then switch to Medicaid.
Nursing homes are not required to keep track of a patient’s use of Medicare benefits. Medicare coverage is inherently complicated. These benefits pay for a stay in its entirety for a specified number of days. After that, it pays a predetermined amount for an additional period under certain circumstances. After their Medicare benefits are exhausted, they are responsible for the bill, unless they have other coverage such as long-term care insurance.
Unfortunately, the nursing home is not legally required to inform a resident or their family members that their benefit days are coming to an end. The care facility can continue to charge them for their care without notifying anyone, which often comes as an unpleasant surprise to the resident and their family members.
However, if the resident’s original Medicare benefits run out before expected due to determinations that the care is no longer medically reasonable or necessary, the nursing home must notify the resident that the coverage is terminating, when it is terminating, and why. They must also inform the resident that they will be responsible for additional costs and provide an estimate of those costs. One action the care facility usually can’t take, however, is requiring another family member to pay for the resident’s care as addressed in the Nursing Home Reform Act.
How Do You Know if a Nursing Home is Billing Accurately?
You want your loved one to receive the best care possible. However, you also want to ensure that the nursing care facility is billing correctly and not overcharging for their services. A nursing home resident or their loved ones should review their bills carefully to ensure them for accuracy. You have a right to know what the bill entails and how much will be on your bill. The nursing home should provide you this information upon request.
Most nursing homes bill monthly for the care they provide. Your contract should spell out the frequency of your billing.
The rate billed is based on a variety of factors, such as the:
- Complexity of care
- Level of services received
- Room type (whether it is private or semi-private)
- Other amenities available
It’s essential to know what you are looking for when examining a nursing home bill for accuracy.
Know the Usual Billing Amount
Unless there is a change in insurance coverage or who will pay the bill, or the care facility resident agreed to pay for extra services, the amount of the monthly bill should remain the same from one month to the next. This is the quickest and easiest way to assess if anything is amiss with your loved one’s bill. If the amount differs, then you will want to begin dissecting each line item to determine why it is different and if the difference is justified.
Check for Separate Charges
Some nursing homes bill separately for certain supplies and services, for example:
- Wound dressings
- Incontinence products
- Catheter supplies
- Physical therapy
Most of the time, these separate charges are not justified and you should not pay them. If Medicare or Medicaid covers the resident’s nursing home bills, the nursing home is not authorized to charge more than a deductible or copay as authorized by law. However, care facilities can bill separately for certain non-health-care items.
This includes, for example:
- Entertainment outside the scope of the activities program
However, the nursing home can only assess an additional charge if the resident requested the item after receiving written notice of the cost.
As a general rule, care facilities cannot impose charges without advance notice, no matter what they are for. This would be similar to a landlord charging $1000 for rent and then billing $1000 for rent and another $50 for the use of the stove and $75 for the use of the refrigerator.
If you or a loved one spot these types of additional charges on the bill, you should likely first talk to the nursing home. If they refuse to remove the charge, you can refuse to pay the unauthorized charges. Pay only what you owe for regular charges along with a written explanation of why you don’t owe the separate charges. In most cases, the nursing home won’t be happy but will accept your payment as payment in full, nonetheless. If they still make a big deal or proceed with steps for eviction, you may want to contact an attorney about unlawful billing practices and care facility evictions.
Look for Services or Treatments Not Received
No matter what party is footing the bill for the care facility, you should always look for bills for services or treatments it didn’t provide. Some nursing homes will add these items to the bill and even bill Medicare or Medicaid for them when your loved one never received those services. If you find something of this nature on the bill, be sure to seek clarification with the nursing home and learn more about nursing home billing practices’ legalities.
Copay and Deductible Charges
Make sure to examine any copay or deductible charges on the care facility bill. For example, if Medicare is the payor, the resident should not have to cover any copays before day 21 of their stay. Whether private long-term care insurance or Medicaid or Medicare coverage is available, you will also want to ensure that you or your loved one is charged the right amount for the copay or deductible.
Charges for Holding a Bed
If your family member takes a leave of absence from the nursing home for whatever reason, perhaps a hospital admission, you need to know beforehand how the situation will go. If Medicaid is handling the charges, the facility should hold their bed at no cost. However, if you signed a bed hold waiver upon your loved one’s admission, they could be on the hook for their charges while they are in the hospital or otherwise not in the care facility. If your family member took a leave of absence during the last billing cycle, be sure to review the bill to determine if the charges were accurate and appropriate.
Your Options for Billing Concerns and Problems
Whether they are for-profit or not, care facilities in the United States must comply with federal and state laws. These laws include regulations about billing and insurance coverage. You have the right to question your or your loved one’s nursing care facility’s billing practices and examine them for accuracy. If you don’t believe the bill is correct or need further clarification, you also have the right to speak to someone about it and seek outside help if needed.
You should first raise any billing questions or concerns with the nursing home itself. If you attempt to address your billing concerns and problems with the nursing home and are unsuccessful or meet obstacles, you have several options.
At times, you or your family member may benefit from the assistance of a nursing home attorney or another advocate. A nursing home attorney will be familiar with the laws in your state and might even be familiar with your nursing home and its billing practices. They can review the bill for accuracy and pinpoint any questionable or illegal practices.
A lawyer can talk to the nursing home about your bill and see if they can resolve the matter outside of court. If the nursing home stands their ground, your attorney can file a lawsuit on behalf of you or your loved one, seeking to rectify the billing problem and compensate you for any damages.
Another reliable source of help is the long-term care ombudsman program. Every state has an ombudsman program to advocate for care facility residents and their families at no cost. You can find contact information for your state’s ombudsman program at the website of the National Long-Term Care Ombudsman Resource Center.
Each state maintains an inspection agency (typically a division of the state’s Health Department) that issues state licenses, monitors nursing homes’ compliance with the Reform Law, and certifies nursing homes for participation in Medicare and Medicaid. Each of these agencies will investigate a resident or family member’s complaint and can give warnings or assess penalties to force a nursing home to address a particular violation.
Other helpful resources include:
- The National Consumer Voice for Quality Long-Term Care which features many informational and helpful publications for nursing home residents and their families
- As previously mentioned, the federal government’s Nursing Home Compare website provides extensive information on individual nursing homes in addition to staffing numbers
To learn more about your legal options, contact Brauns Law, PC.