Court says nursing home's 'custodial' care not eligible for reimbursement

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A court has ruled that a Wisconsin nursing home is not entitled to reimbursement for the services it provided to a resident, because the care was later deemed medically unnecessary.

The U.S. District Court for the Eastern District of Wisconsin ruled that the care Samaritan Health Center provided to Mary Ann Bowe, who participated in the Simplicity Health Care Plan, was primarily custodial.

While the judge did find that Bowe's care involved some medical monitoring that had to be performed by people with medical training, the nursing home essentially was assisting her with activities of daily living that could be carried out by nonmedical personnel. Therefore, the 228-bed nursing home was not entitled to reimbursement under the self-insured health plan.

Bowe was admitted to Samaritan Health Center for low blood sugar and seizures related to congestive heart failure, vascular disease and insulin-dependent diabetes. At that time, both agreed the admission was medically necessary under the plan, but after a month in the nursing home the plan found that the care she was receiving was not covered under the plan, according to court records.

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