Edwina Kirby was having a hard time. She had tripped over a rug in her home in Livonia, Mich., and the fall broke a femur. After she had surgery and rehabilitation, an infection sent her back into the hospital. Her kidneys failed, requiring dialysis; she was also contending with diabetes and heart disease.
By the time she entered Glacier Hills Care and Rehabilitation Center, a nursing facility in Ann Arbor, "she couldn't even feed or dress herself," said her daughter Deanna Kirby, 55. "She was basically bedridden."
For months, physical therapists worked with Mrs. Kirby, a retired civil servant who is now 75, trying to help her regain enough mobility to go home. Then her daughter received an email from one of the therapists saying, "Edwina has reached her highest practical level of independence."
Translation: Mrs. Kirby wouldn't receive Medicare coverage for further physical therapy or for the nursing home. If she wanted to stay and continue therapy, she'd have to pay the tab herself.
Medicare beneficiaries often hear such rationales for denying coverage of skilled nursing, home health care or outpatient therapy: They're not improving. They've "reached a plateau." They're "stable and chronic," or have achieved "maximum functional capacity."
Deanna Kirby wasn't buying it. "I knew they couldn't refuse you, even if you're not improving," she said.
She's right. A federal judge last month ordered the federal Centers for Medicare and Medicaid Services to do a better job of informing health care providers and Medicare adjudicators that the so-called improvement standard was no longer in effect.