Current estimates are that the number of individuals needing or using long-term care services in any setting – such as SNFs, assisted living or home care – could reach 27 million in the next 30 years.  While this may seem like an amazing number to grasp, it is realistic considering that some 10,000 people will turn 65 every day between now and 2029 and that an estimated 70 percent of them will require long-term care at some point in their lives.

Long-term care services are designed to meet the needs of frail older people, and other adults whose capacity for self-care is limited because of chronic illness, injury, physical, cognitive, mental disability, or other health-related conditions. The financial cost of providing this care will be equally astounding.  Using the current spend on long-term care of $300 billion as a reference, it is clear that that the vast majority of individuals and families cannot and will not be able to cover these costs themselves.

So, who is picking up this tab?  Currently, the Federal Medicaid and Medicare programs cover 47 percent and 23 percent respectively; about 23 percent is covered by families and about 3 percent by private long-term care insurance.

While only about 10 percent of people who may need long-term care have private insurance policies, many were underwritten to include benefits that have become, in many cases, cost-prohibitive.  Combining these costs with the increasing outlays that Medicare and Medicaid will necessarily need to make may create increasing financial pressure on both private and public payors.  And, as is the case now with short-term (hospital) care, payors will increase the reasons to deny reimbursement to control costs.

Some areas that payors may immediately target as potential denials are what they refer to as ADL, or assistance with activities of daily living, which include medication management, housework, and health maintenance tasks.  Other areas could include maintaining or improving levels of physical function; special equipment and assistive devices; and home-health assistance from third-parties.

It’s also important to keep in mind that the LTC service delivery system has changed over the past two decades.  Although nursing homes are still a major provider of LTC services, there is a growing use of skilled nursing facilities (SNF) for short term post-acute care and rehabilitation. Individuals also now have more options for tapping in to home and community-based alternatives, including adult day service centers, assisted living, residential care, home health agencies and hospice care.  As can be expected, with expanded service options come expanded potential problems including financial challenges, operational challenges and increased reimbursement claim denials.

Many of these are exacerbated by the inherent differences between long-term care and normal healthcare issues, which can create an entirely new set of financial, operational and legal problems for providers. These need to be taken in to account by providers both looking to expand their services to long-term care as well as existing providers of LTC services wanting to be better prepared to meet their current operational and financial challenges.

Generally, these challenges are the result of existing SNF policies affecting resident care, admissions, reimbursement, and evictions that may violate federal and state nursing home reform laws and regulations.  These may include the common practice of evicting residents they consider difficult, despite the fact that eviction is only allowed for several reasons: failure to pay, a resident no longer needs nursing home care, a resident’s needs cannot be met, a resident endangers others’ safety or health, or the facility is going out of business.

There are other common practices or false beliefs that may run afoul of local, state or federal regulations that providers need to be aware of and continually updated on to avoid costly legal or regulatory actions as well as avoid creating causes for reimbursement claim denials.   These include:

• Medicaid does not pay for a specific service: Medicaid residents are entitled to the same services as other residents.
• Only staff can determine the care received: Both residents and their families have the right to participate in developing a care plan.
• Need to hire private help for a patient: Nursing homes and other facilities must provide all necessary care.
• Restraints are required to prevent the resident from wandering away: Restraints cannot be used for nursing home convenience or discipline.
• Family visiting hours are restricted: Family can visit at any time of the day or night, 24/7.
• Therapy must be discontinued because the resident is not progressing: Therapy may be appropriate even if the resident is not progressing and Medicare may pay even without current progress.
• Any amount set by the facility for extra charges must be paid:  A nursing home may only require extra charges authorized at the time of admission.
• The facility has no available space for residents or family members to meet: A nursing home must provide a private area for resident and family meetings.
• The resident may be evicted if he or she if difficult or refusing care: Being difficult or refusing care does not justify eviction.

In addition to complying with myriad local, state and national regulations, providers of SNF and long-term care also need be prepared to address – and challenge – a variety of reasons that payors may use in an attempt to deny reimbursement claims.  These include, but definitely are not limited, to:

• Nursing home assessment shows resident is not cognitively impaired
• Nursing home assessment shows that the beneficiary does not need assistance with ADL (Activities of Daily Living)
• Plans ignore medical necessity qualification, and deny based on another policy provision
• Plans review the medical necessity “trigger” but not necessary in a nursing home or assisted living environment
• The facility selected does not qualify under the plan’s provisions as a nursing home
• No return of phone calls or any response to correspondence
• Claims are delayed unreasonably
• Plans require unnecessary documentation
• Unreasonable interpretation of the applicable Long-term Care Policy
• Plans claim preemption of the plan under state or federal law

In conclusion, the difficulties encountered in this very different environment of healthcare are much different than what many providers, patients and families are used to.  If a provider finds themselves facing these types of challenges, they may very well require advice from knowledgeable people inclusive of legal advice to handle this very necessary care for an ever-increasing population.