Under this system, HHAs are paid on the basis of a 60-day episode of care in accordance with standard payment amounts (42 U.S.C. [4] A different notice – a Notice of Exclusions from Medicare Benefits, SNF NEMB, CMS Form 20014 – may be used by a SNF (although its use is not required by CMS) if the beneficiary has no days left in the benefit period. (42 U.S.C. It is therefore important that notice is: Discharge planning should result in a written document, a discharge plan. 42 C.F.R. A statement of the right to file an appeal or raise questions with a QIO about quality of care, including hospital discharge. For hospitals with an approved swing bed arrangement, providers should use Code 61- Swing Bed. 105-33 (Aug.5, 1997) §4432(a), amending §1888 of the Social Security Act by adding subsection (e), 42 U.S.C. However, hospitals are not precluded from obtaining a new IM and verifying signature from the beneficiary. §424.22(a)(1)(v). Medicare requires that when discharging a patient from an inpatient stay, that the … Often, these patients are expensive to treat. Facilities are to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment (42 C.F.R. §§409.31(b)(1)-(5); 409.32; 409.33). Beware of using physicians who have opted out of Medicare and the impact of using such physicians and consequent impact on access to Medicare coverage for the services. Filed Under: Article Tagged With: Coverage & Appeals, Discharge Planning, Skilled Nursing Facility, Weekly Alert. The expedited appeals process is intended to keep Medicare-covered services continuing, without interruption. It’s the law! Facilities are to develop a post-discharge plan of care, developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. If a SNF decides that Medicare will no longer cover an item, service, or procedure and the facility wishes to bill the beneficiary, it must give the beneficiary written notice of non-coverage, including information about the right to request an appeal of the facility’s non-coverage decision and the steps to take to exercise that right (42 U.S.C. The regulations establish that a face-to-face encounter must have “occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter.” In addition, the certification of the need for home health care must include an explanation as to why the physician’s clinical findings support the need for home health care, including that the patient is homebound and the need for either intermittent skilled nursing services or therapy services as defined in 42 C.F.R. If the service is a Part B service, but it “falls outside of a timeframe for receipt of a particular benefit,” then the hospital must give the beneficiary an ABN. Section 332 of the Benefits Improvement and Protection of Act of 2000 (BIPA), Pub. The SNF must give notice to the beneficiary at least two days prior to termination of all Part A services when the beneficiary still has days left in the benefit period,[4] using the Notice of Medicare Provider Non-Coverage, Form CMS-10123, to inform the beneficiary of how to request an expedited redetermination and, if the beneficiary seeks an expedited determination, the Detailed Explanation of Non-Coverage (DENC), Form CMS-10124. 1989)). This Transmittal includes 10 different forms for Hospital –Issued Notices of Non-coverage (HINNs), none of which addresses observation status. §1395x(ee); 42 C.F.R. [33] 42 U.S.C. clearly identify anticipated dates of discharge; clearly identify whether it is the facility’s notice or that of the Medicare or Medicaid agency, or other entity; and. The regulations permit hospice programs to discharge patients under only three circumstances: The patient moves out of the hospice’s service area or transfers to another hospice; The hospice determines that the patient is no longer terminally ill; or. Inpatient Hospital/Skilled Nursing Facility (SNF) DMEPOS Claim Submission Reference Aid This reference aid provides step by step instructions on how to determine if an item may be billed to the DME MAC for some of the most common inpatient hospital and skilled nursing facility discharge … In the past, the Center’s primary focus was how time in observation status and in the emergency room was not counted by the Medicare program when that time was followed by a beneficiary’s formal admission to the hospital as an inpatient. Note, after April 1, 2011, the notice of discharge forms with approval dates of 05/07 will not be valid. §418.22(b)(4). • Visit . The standard appeals process serves a similar function of enabling a beneficiary to seek Medicare payment for a SNF stay, but it is also necessary to inform the beneficiary of possible non-coverage and, if Medicare agrees that coverage is not appropriate, to shift the costs of care from the SNF to the beneficiary. [8] https://www.keproqio.com. [24] 42 C.F.R. This Alert sets out the notice and appeal rights for both Medicare coverage and nursing home transfers and discharges. On the date that the QIO receives the beneficiary’s request, the QIO must notify the hospital that the beneficiary has filed a request for expedited review. §483.12(d)(1), (2)). The case, Bagnall v. Sebelius (No. (See Pub. [26]  These notices are used at the initiation, reduction, or, as relevant for this discussion, termination of Part A-covered care in traditional Medicare for level of care reasons. . Arranging, when requested by a patient’s physician, for the development and the initial implementation of a discharge plan for the patient. [15] 42 C.F.R. §405.1202(f)(1)(ii). §484.10(c)(1) and (2). If the patient indicates that she wishes to appeal, the proposed regulations require that a detailed follow-up notice with specifics about the medical reasons for individual’s discharge be given to her by noon of the next day. The hospice is, however, to: Advise the patient that a discharge for cause is considered; Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation; Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and. Cal. In the Guidance, CMS explains when and how Medicare patients must be given information about their discharge and appeal rights. Regulations also provide that a face-to-face encounter can be by tele-health as provided in §1834(m) of the Social Security Act. ; Sarrassat v. Sullivan, Medicare and Medicaid Guide (CCH), ¶38,504 (N.D. Cal. If you leave the nursing facility after coverage begins, but are readmitted within 30 days, that second period in the nursing facility will also be covered by Medicare. §1395i-3(c)(5)(A); 42 C.F.R. Involuntary discharge of nursing home (NH) residents is a prominent reason for NH complaints in the United States, but little is known about facility-initiated involuntary discharge (FID). See the Medicare Claims Processing Manual (Pub. 17052. See also 42 C.F.R. [1]  The truth is that when a SNF tells a beneficiary that he or she is “discharged,” (1) at that point, Medicare has not yet made any determination about coverage and (2) a resident cannot be evicted solely because Medicare will not pay for the stay. The plaintiffs sought a requirement that Medicare beneficiaries are given timely written notice of the reasons for their discharge and of the procedures for appealing a discharge decision. If the beneficiary has opinions and concerns about care, make sure they are voiced and assure that the beneficiary participates fully in all care decisions. However, to allow providers the opportunity to establish operational protocols necessary to comply with the face-to-face encounter requirements, full implementation was delayed. §418.26(a). Similarly, good discharge planning for patients, their families, and their healthcare providers, paves the way to successful transitions from one care setting to another. What Information Must the Important Message from Medicare (“IM”) Contain? Managing your care at home after an inpatient hospital or skilled nursing facility (SNF) stay can be confusing and difficult. Discharge Planning in the Home Health Care Setting. [17] 42 C.F.R. 42 C.F.R. Note: The PPS RUG-III system does not change Medicare skilled nursing facility (SNF) criteria for admission or services. §422.584. In addition, the failure to be placed in a high RUG category does not automatically mean that the beneficiary would be denied SNF coverage under Medicare. A Medicare beneficiary has the right to refuse a transfer from a portion of the facility that is a skilled nursing facility to a portion that is not a skilled nursing facility (42 U.S.C. If the medical review upholds the decision of the HHA that the services were not coverable, the HHA keeps the funds collected from the beneficiary. [27], In 2009, CMS clarified that the SNF ABN is separate from the notices required in expedited appeals and that a SNF must use a Denial Letter or SNF ABN to “fulfill the provider’s obligation to advise the beneficiary of potential liability for payment.”[28]  If the SNF fails to provide this notice to the beneficiary, it may not shift the costs of care to the beneficiary. See 42 CFR 405.1204. [3], Expedited Determination, 42 C.F.R. Further, the burden of proof lies with the hospital to demonstrate that the discharge is the correct decision based on either medical necessity or other Medicare coverage policies. Medicare covers skilled nursing facility (SNF) care. 42 C.F.R. resources that are available to help with costs attendant to care. See the Medicare Benefits Policy Manual, Chapter 15- Covered Medicare and Other Health Services, §40-4, Definition of Physicians/practitioners. Use of Condition Code 44 is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols. [37] 42 U.S.C. Has the facility aided the resident and his/her family in locating and coordinating post-discharge services? 42 C.F.R. 42 C.F.R. A follow-up copy of the signed IM should again be given “as far in advance of the discharge as possible, but not more than 2 calendar days before discharge.” If discharge occurs within 2 days of the date the IM was given, no follow-up copy is required. §405.1202(f)(1)(i). The discharging facility should ensure that documentation in the patient’s medical record supports the billed discharge status code. §405.1202(c). Religion under certain conditionsIf you believe you've been discriminated against, contact the Department of Health and Human Services, Office for Civil Rights. By allowing this practice, CMS has made it possible for hospitals to eliminate the need for a follow-up copy of the IM during inpatient stays of up to 5 days. What types of pre-discharge preparation and education has the facility provided the resident and his/her family? Specific information about the patient’s current medical condition. A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility (42 C.F.R. Check them out: Medicare covers skilled care to maintain or slow decline as well as to improve. §1395i-3(c)(2)(B)(i)(I). Important informational tools for caregivers. §1395i-3(c)(2)(A)(i)-(vi); the Medicaid law is identical, 42 U.S.C. The PPS for home health relies on a patient assessment instrument, the Outcome and Assessment Information Set (OASIS), as part of the process of determining the PPS amount the home health agency will be paid for each patient (42 C.F.R. If Medicare does not pay for a resident’s stay, the resident must have another source of payment, typically out-of-pocket payments or Medicaid. 1989), HCFA Ruling 95-1 (Dec. 22, 1995); HCFA SNF Manual, Chapter 3, §357A (establishing when the beneficiary is on notice of non-coverage); §352.1 (determining beneficiary liability)). The same caution applies to using suppliers who have opted out. Discharge planning rights in the home health care arena are not as well developed as in the hospital and nursing facility context. A Medicare beneficiary has the right to refuse a transfer from a portion of the facility that is a skilled nursing facility to a portion that is not a skilled nursing facility (42 U.S.C. [36] 42 U.S.C. §418.26(d). See, http://edocket.access.gpo.gov/2006/pdf/06-3280.pdf (site visited May 15, 2015). The beneficiary, therefore, should not be discharged upon requesting the QIO review, so long as the request is made on the same day. The right of readmission is an immediate right to the first available bed in a semi-private room (42 U.S.C. [10], If the SNF does not provide timely information to the BFCC-QIO, it may be financially responsible for providing covered care to the beneficiary. The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause…that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. “Discharge” from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? to compare the quality of home health agencies, nursing homes, dialysis facilities, inpatient rehabilitation facilities, and hospitals in your area. §1395bbb(a)(1)(A), 42 C.F.R. 9, available at www.cms.hhs.gov/Manuals/IOM (site visited May 18, 2015). The QIO must inform the provider of the appeal, and the provider must supply the beneficiary with a more detailed notice. They are also charged for their entire subsequent SNF stay, having never satisfied the statutory three-day inpatient hospital stay requirement, as the entire hospital stay is considered outpatient observation. Such a retroactive change may be made, however, only if (1) the change is made while the patient is in the hospital; (2) the hospital has not submitted a claim to Medicare for the inpatient admission; (3) a physician concurs with the UR committee’s decision; and (4) the physician’s concurrence is documented in the patient’s medical record. Medicare Coverage Requirements for Skilled Nursing Facilities. The link to access this resource is at the bottom of this page. Check them out: Medicare covers skilled care to maintain or slow decline as well as to improve. 42 C.F.R. This saves money, and, in some instances, extends rights and recourse that would not otherwise be available, particularly when using non-participating suppliers. The policies must be consistent with the provisions of the state Medicaid plan regarding bed-hold (42 U.S.C. Estate of Landers v. Leavitt, 545 F.3d 98 (2d Cir. This notice is to explain a patient’s rights as a hospital patient including discharge appeal rights. This also means that a hospital may find that a patient awaiting SNF placement no longer requires inpatient hospital care because either a SNF-level bed has become available or the patient no longer requires SNF-level care.” 42 C.F.R. §424.22(a)(1)(v)(A). CMS has developed a model notice, the SNFABN, which facilities may use (Form no: CMS-10055; MCM, Pub. Patients in these circumstances do not get a notice of a denial of admission and in fact may not even know that they have been evaluated for purposes of a skilled nursing facility admission. Litigation challenging CMS’s method of calculating hospital time was unsuccessful. §484.200 et seq.). 42 U.S.C. [13] 42 C.F.R. When a beneficiary receives an HHABN stating that services will be terminated, he or she may request that the home health agency submit a demand bill—for further information please see the Medicare Claims Processing Manual (Pub. The only definition appears in various CMS manuals, where observation services are defined as: a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital; and in most cases, according to the Manuals, a beneficiary may not remain in observation status for more than 24 or 48 hours. The latest version of the “Important Message from Medicare” requires hospitals to note the time of delivery. 42 C.F.R §418.22(b)(5). [10] 42 C.F.R. The beneficiary or qualified representative should be contacted by the QIO to discuss the case with the QIO and provide any necessary information that may be required. A SNF’s statement that Medicare will not pay for a beneficiary’s stay is the SNF’s determination; it is not Medicare’s determination. If the basis for the SNF’s decision is its contention that the beneficiary “plateaued” or is unlikely to improve further, the beneficiary should bring to the BFCC-QIO’s attention that this basis for “discharge” is prohibited under the settlement in Jimmo v. [18] 42 C.F.R. §1395i-3(c)(2)(B)(iii)(II). Two processes are available: the (newer) expedited appeals process and the (older) standard appeals process. §483.10(o)). 42 CFR §484.10(a)(1), (2). Skilled nursing facilities (SNFs) often tell Medicare beneficiaries and their families that they intend to “discharge” a Medicare beneficiary because Medicare will not pay for the beneficiary’s stay under either Part A (traditional Medicare) or Part C (Medicare Advantage). [7] 42 C.F.R. Assuring that discharge planning evaluations and discharge plans are developed by, or under the supervision of, a registered professional nurse, social worker, or other appropriately qualified personnel. §409.42(a) and (c). §483.20(l)). Private health care coverage, services under the Older Americans Act, Medicaid, and other home and community-based health care may be useful options. Medicare beneficiaries and their advocates who question the appropriateness of a proposed discharge from a Medicare hospital, whether the discharge is too soon or whether necessary post-hospital services have been arranged, should contact the local Quality Improvement Organization (QIO) and file a complaint. If the patient or representative refuses to sign the IM, then the hospital is required to make a note to that effect; for purposes of requesting an appeal, the date of the refusal to sign is considered the date of notification. The Center for Medicare Advocacy produces a range of informative materials on Medicare-related topics. Post-discharge plan of care means the discharge planning process, which includes assessing continuing care needs and developing a plan designed to ensure the individual’s needs will be met after discharge from the facility into the community (42 C.F.R. Medicare Part A covers the cost of a skilled nursing facility for conditions that begin with a hospital stay and require ongoing care after discharge. §405.1202(f)(1)(iii). 186 F. Supp.2d 105 (D. Conn. 2001). See “. This notice is called a home health advanced beneficiary notice (HHABN). [30] Nursing facility is the term used by the Medicaid program. Placing the discharge planning evaluation in the patient’s medical record for use in planning post-hospital services. 3:11-cv-01703, D. Conn), states that the use of observation status violates the Medicare Act, the Freedom of Information Act, the Administrative Procedure Act, and the Due Process Clause of the Fifth Amendment to the Constitution. Home health agencies (HHAs) are required to give written or oral notice concerning when Medicare will pay for services and when there is a change. See 42 CFR 405.1205 (Traditional Medicare) and 42 CFR §422.620 (Medicare Advantage). The facility cannot bill the beneficiary for the disputed charges until the Medicare fiscal intermediary issues a formal claim determination (Medicare Intermediary Manual §3630; Sarrassat v. Sullivan, Medicare and Medicaid Guide (CCH), ¶38,504 (N.D. Cal. They should keep in mind that the issue of paying for services pending an appeal will be difficult for many beneficiaries. 42 CFR §405.1206(e)(2); 42 CFR §422.622(e)(2). [6] 42 C.F.R. 100-02, Chapter 6, §20.6.C. Moreover, QIOs have an obligation to assist Medicare beneficiaries in completing and filing a written complaint. §422.622(f)(2). 100-04, Ch. §405.1202, The purpose of an expedited appeal is to keep services in place. §422.622(c). [22] Jimmo v. Sebelius, Civil Action No. Medicare beneficiaries throughout the country are experiencing the phenomenon of being in a bed in a Medicare-participating hospital for multiple days, sometimes over 14 days, only to find out that their stay has been classified by the hospital as outpatient observation. This new policy can be found in Chapter 9 of the Medicare Benefit Policy Manual. 3:11-cv-01703, D. Conn), filed on November 3, 2011. 10, § 50) for additional information on demand billing under the Home Health Prospective Payment System (HH PPS). See Medicare Benefit Policy Manual, Ch. 42 CFR §405.1206(b)(2); 42 CFR §422.622(b). §1395i-3(c)(2)(C). 42 CFR §405.1206(b)(1); 42 CFR §422.622(b)(1). Is there evidence of discharge planning in the records of discharged residents who had an anticipated discharge or those residents to be discharged shortly (e.g., the next 7-14 days)? In addition, your stay in the nursing facility must begin within 30 days of being discharged from the hospital. A frail or chronically ill person need not show deterioration or medical setback in order to justify skilled nursing observation and assessment, including the observation and assessment of acute psychological problems in addition to physical problems (42 C.F.R. [7]  There are two BFCC-QIOs serving different parts of the country – KEPRO[8] and Livanta. [11] 42 C.F.R. If the service is not a Part B service, an ABN is not required in order to shift liability to the beneficiary, though the hospital may voluntarily give the patient such notice. [9] http://bfccqioarea5.com/. §483.20(b)((xvi)). Beneficiaries who are billed for prescription drugs during their hospital stay should use their Part D plan’s process for submitting claims from an out-of-network pharmacy (assuming the hospitals’ pharmacies do not participate in Part D plans, as most do not). §405.1202(c), (e)(7). §1396r(c)(2)(D); (42 C.F.R. 42 C.F.R. (In unusual cases, … L. No. In order for the review request to be considered “timely,” beneficiaries must submit their requests in writing or by telephone no later than midnight of the day of discharge and before they leave the hospital. Reg. [12] The burden of proof is on the SNF to prove that termination of services was correct.[13]. 1-800-MEDICARE … Pay attention to access to coverage concerns that may arise from recently instituted Medicare rules that exclude and limit payment for hospital acquired conditions (HACs) and things that should never happen in hospitals (never events). The notice, “An Important Message from Medicare about Your Rights” (IM), can be found on the CMS website at http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp (site visited May 15, 2015). §412.42(c)(1)-(3). §412.42(c)(1); 42 C.F.R. §405.1202(f)(3). See Medicare Benefit Policy Manual, CMS Pub. It is important to explore options for obtaining and paying for services that may be available through private and state-based sources of coverage for home and community-based services (HCBS). [19] 42 C.F.R. 42 C.F.R. Identify and become familiar with available health care services such as visiting nursing services, home health agencies, nursing homes, respite care, friendly visiting services, and religious and civic groups that provide services. [2]  CMS provided a helpful summary of the various notices in 2014. §424.22(b)(1). 42 C.F.R. [25] 1989 WL 208444 (N.D. Cal May 17, 1989). The provider must give notice 2 days before loss of services occur. 100-02, Chapter 6, §20.6; the same language is in Medicare Claims Processing Manual, CMS Pub. §§424.13(b)(1), 412.42(c)(1)). A beneficiary is presumed not to know “that services are not covered unless the evidence indicates that written notice was given to the beneficiary.” See Medicare Claims Processing Manual, CMS Pub. • Call . §483.12(a)(7)). [12] 42 C.F.R. National origin 4. Notice issues are confusing and complex. To implement the new statutory requirement, the Centers for Medicare & Medicaid Services (CMS) made changes to 42 C.F.R. The hospital is required to submit all pertinent information to the QIO. Medicare regulations require that hospice programs perform discharge planning. “Facts specific to the beneficiary and relevant to the coverage determination . 42 C.F.R. If unable to do so, have family members, friends, or other representatives read such document(s). [34] 42 U.S.C. provided to the patient or family member, or other person capable (by permission and capacity) of understanding and acting on the notice information. The patient must have been an inpatient of a hospital facility for a minimum of three consecutive days. 106-554 (Dec. 21, 2000), amends §1814(a) of the Social Security Act, 42 U.S.C. 26, 2014),   http://www.wpsmedicare.com/j5macparta/training/on_demand/_files/2014-0326-snf-notices-noncoverage-handout.pdf.
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