What to Do When Rehab Coverage Is Denied
Getting a denial for skilled nursing or rehabilitation coverage can be scary and frustrating, especially when you're already dealing with a health crisis. But a denial isn't the final word—you have options.
Why Denials Happen
Common reasons:
- Medicare determines skilled care is no longer "medically necessary"
- Progress has plateaued or goals have been met
- The condition is considered maintenance rather than improvement
- Documentation didn't support the need for continued care
- Didn't meet the 3-midnight hospital stay requirement
Your Rights After a Denial
You have the right to:
- Receive written notice explaining the denial
- Appeal the decision
- Stay in the facility during the appeal (with some conditions)
- Request an expedited review for urgent situations
The Appeals Process
1. Immediate steps:
- Request the denial in writing
- Ask the facility's social worker for help
- Note the deadline for appeal (often 60 days, but act quickly)
2. First level appeal:
- Submit a written request for reconsideration
- Include supporting documentation from physicians
- Explain why continued care is medically necessary
3. If denied again:
- Request a hearing with an Administrative Law Judge
- Higher levels of appeal exist beyond that
Alternative Options
If the appeal doesn't succeed or you need immediate solutions:
Short-term:
- Private pay for continued rehab (often at a daily rate)
- Transfer to a lower level of care (assisted living with therapy)
- Home health services for continued therapy at home
Longer-term planning:
- Outpatient rehabilitation
- Adult day health programs
- In-home physical therapy
How to Prevent Denials
- Ensure the hospital stay is classified as inpatient (not observation)
- Communicate clearly with the care team about ongoing needs
- Document progress and setbacks
- Advocate for continued therapy when improvement is still possible
Getting Help
- Hospital social workers and case managers
- State Health Insurance Assistance Program (SHIP)
- Medicare ombudsman
- Elder law attorneys for complex situations
- Senior placement advisors who understand the system