Legal Eagle Eye Newsletter for the Nursing Profession(4)3 Dec 95


   Quick Summary: The three-day hospitalization requirement for Medicare reimbursement for admission to a skilled nursing facility has been upheld by a Federal court.

   A patient, ninety-one years old, fell at home and broke her wrist. She went to a hospital to have the wrist casted, and stayed overnight. Three days later she returned to the hospital from her home because her hand had turned blue. The cast was removed, and she was sent to another hospital to be admitted to its skilled nursing facility for rehab. This admission resulted in her being billed over $10,000 which was not covered by Medicare.

   The patient sued the Secretary of Health and Human services in the Federal District Court for the Southern District of New York, for a determination of her rights as a Medicare beneficiary.

   A skilled nursing facility is meant to provide extended care services to individuals who require post-hospital rehab or skilled nursing care. The court ruled that to qualify for Medicare coverage in a skilled nursing facility, an applicant must have been admitted to a hospital for at least three consecutive days immediately prior to admission to the skilled nursing facility. The applicant’s knowledge or lack thereof of this requirement is irrelevant.

   However, the court did concede its decision might seem somewhat unfair to someone with a sense of justice, but said only Congress can change the laws. Lewin vs. Shalala, 887 F. Supp. 74 (S.D.N.Y., 1995).

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