Failure to Honor POA Authority Over Resident’s Insurance and Financial Affairs
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s power of attorney (POA) right to manage the resident’s financial affairs, specifically the right to select and control the resident’s insurance payer source. The resident was admitted with severe cognitive impairment, was dependent on staff for all ADLs, and had multiple serious medical diagnoses including nontraumatic intracerebral hemorrhage, metabolic encephalopathy, acute respiratory failure, hemiplegia, severe protein malnutrition, and a tracheostomy. At admission, the primary payer source was Aetna Managed Medicare. The admission agreement’s Designation of Authorized Representative page for the Ohio Department of Medicaid listed the facility’s Business Office Manager as the representative, but the form only contained a hand-printed initial and last name of the resident’s POA in the signature box of the person granting authority, with no signature from the authorized representative. The form itself stated it had no effect unless signed by both parties. On a later date, the primary payer source was changed from Aetna Managed Medicare to Medicare A, and then subsequently to private pay, without any documented evidence that the facility discussed these changes with the resident’s POA. An invoice dated shortly after the payer change showed the resident was billed coinsurance of $209 per day for a specified period, totaling $4,399.50, with a due date the following month. The resident’s family member and POA reported they did not authorize any insurance changes and were not asked for permission to change the insurance payer source, and they believed the Business Office Manager had made the change without consent. Facility staff, including the Accounts Receivable Supervisor and Business Office Manager, confirmed the resident had been charged $209 per day due to the payer change and that a bill had been issued, but they denied making or knowing who made the change. The POA stated that, due to the disenrollment, the resident accrued expenses from the facility and other providers, and that the facility had not sought her permission to alter the insurance payer source.
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