“Clear as M.U.D.” presents actual stories of payment denials that appear on the surface to be difficult to explain. Fiscal Intermediaries and QICs are supposed to deny or recoup payments when a service to a patient appears to be a Medically Unbelievable Claim. On occasion, this can result in what we call a Medically Unbelievable […]
We may not always have a Medically Unbelievable Denial story to offer every week but this one could not wait until next month. This episode was denied, in part, because “home health care agencies are paid more when they provide more therapy services.”
There was never a question that this Congestive Heart Failure patient was homebound and eligible for the Medicare home health benefit. If the Stasis ulcer on her leg was not serious enough to keep her mostly bedridden, her 103-year old, failing heart certainly restricted her ability to get out and about without “considerable and taxing effort.”
The result: Medicare home care services for this patient, at a cost to taxpayers of approximately $65 per day, have been replaced by institutional care, at roughly four times that cost to the government.
