What to know if Medicare denies coverage

Transcription

1 What to know if Medicare denies coverage What Medicare covers Necessary post-hospital extended care for up to 100 days Extended care: nursing care and rehab provided to a Medicare beneficiary who is an inpatient in a SNF Nursing care and rehab must be provided daily Condition treated must be a condition for which the patient received hospital services or a condition that arose at the SNF while being treated for the initial condition What Medicare covers Coverage under Part A for first 20 days is in full Copayment for next 80 days 2012 copay: $144.50/day copay amount may be covered by Medicare Supplement Note: if client does not meet Medicare SNF coverage criteria, a WI issued supplement must cover 30 days of skilled nursing care in a SNF. The facility does not need to be certified by Medicare The stay does not have to meet Medicare s definition of skilled care No prior hospitalization may be required The facility must be a licensed skilled care nursing facility. The care must be medically necessary according to the insurer.

2 - Not less than three consecutive days Day of discharge not counted as one of the three qualifying days Check that date the patient brought to hospital is actual admission date If admission logged in by staff after midnight, admission set as next day Must be inpatient, not observation Medicare advantage plans may cover SNF stay without prior threeday hospital stay but are not required to do so - Patient must go to Medicare participating SNF within 30 days of discharge from hospital Limited exceptions: if not medically appropriate to begin the post hospital SNF care within 30 days, and if it is medically predictable at the time of hospital discharge that the patient will need covered care in a pre-determinable time period 30 day transfer requirement also met if beneficiary receiving covered SNF care leaves a SNF and is readmitted to same or any other participating SNF within 30 days of the last covered skilled day Does not require re-hospitalization 1. Skilled nursing services or skilled rehab services are needed 2. Must be performed by or under supervision of professional or technical personnel and ordered by a physician 3. Patient must require services on a daily basis 4. Services can be provided as a practical matter only on an inpatient basis in a SNF; and 5. Services must be reasonable and necessary

3 - vs. custodial: may have custodial services in addition but need daily skilled services included -evaluate inherent complexity of a service provided to patient; may be skilled services when: - conditions are complicated - skilled management of unskilled conditions - Note: when looking at primarily rehab services, key is whether skills of a therapist are needed, NOT whether patient has potential for recovery Skilled NURSING services may include the following when skills of a technical or professional worker are needed: Overall management and evaluation of care plan Observation and assessment of patient s changing condition Patient education services to train and teach self maintenance and management Certain services are per se skilled need to be done once daily: IV injections, IV feeding Treatment of widespread skin disorders Care of colostomy during early post-op period due to associated complications Questionable skilled nursing situations: When patient s primary need is oral medication or who are capable of independent ambulation, dressing or feeding

4 Examples of skilled rehabilitation services Again, need a skilled PT/OT/ST supervising the services but these are usually covered: Ongoing assessment of rehab needs/ potential Therapeutic exercises or activities needing skilled personnel Gait eval and training needed to restore function (no assistant allowed) R.o.M. exercises that are part of active treatment Maintenance therapy when designed and established by qualified therapist Ultrasound treatments Hot packs/ whirlpool baths/ infrared treatment if patient s condition complicated by circulatory or other problems Some examples of non covered therapy: Personal care services Admin of routine oral medication, eye drops, ointments General maintenance of colostomy Changes of dressings for non-infective post-op or chronic conditions Routine incontinence care Palliative skin care (treatment of minor skin problems) Assistance in dressing/eating/going to bathroom General supervision of exercises

5 Remember, restoration potential of the patient is NOT the controlling factor in determining whether skilled care is necessary Skilled care can be necessary for preserving current status or preventing deterioration Skilled nursing care or a combination of skilled nursing services and rehab services must be provided seven days per week Skilled rehab services provided five days per week satisfy the daily requirement Do not apply daily requirement too strictly the requirement may be met even when therapy is suspended in isolated break for a day or two due to fatigue of the patient SNF s can t bill Medicare or the beneficiary for care if beneficiary takes brief leave of absence but is not discharged from SNF (for reasons other than admission to hospital or other SNF) Even if daily skilled services are medically necessary, need to prove that services, as a practical matter, can only be provided in a SNF on an inpatient basis Depends on alternative services available in the patient s area and the feasibility and practicality of services Note: the important issue is feasibility of the alternative care, not whether Medicare will pay for it Important factor is the patient s medical condition if an alternative care setting would adversely affect a patient s medical condition, SNF care is appropriate Home care not an alternative to SNF care if patient does not have sufficient assistance from capable and willing family members

6 Medicare covers maximum 100 days of SNF care during benefit period ( Spell of Illness ) Benefit period begins first day Medicare beneficiary enters SNF and ends when he/she has been 1) receiving less than a skilled level of care or 2) outside a hospital or SNF for 60 consecutive days After either (1) or (2) occurs, need a new three day inpatient hospital stay for a new 100 day SNF coverage period to start Must be some connection between the patient s condition during the hospital stay and subsequent SNF admission Need to ascertain interrelationship between claimant s various illnesses to determine This rule should be construed liberally Refer to all of the conditions treated at the hospital good chance you will find SNF treating same condition Skilled vs. Custodial Care Central evaluation of every SNF coverage determination Focus on inherent complexity of the services Have a checklist, including: Is this a rehabilitation or nursing patient or both? What rehabilitation services have been provided (OT/PT/ST)? Check the list of per se skilled therapy and skilled nursing services Is skilled development, management and evaluation of the patient s care plan required? Is skilled observation and assessment of the patient s changing or unstable condition required? What specific nursing services have been provided? Any special medical complications that require services of skilled personnel?

7 Management and Evaluation of the Patient Care Plan SNF patients are entitled to Medicare coverage if they need and receive skilled observation, assessment, management of care plan or patient education services even if they do not require or receive specific nursing services (ie. injections) Look for the following specific services in SNF medical records: Skilled nursing personnel that develop, manage, evaluate a doctor s plan of care Skilled nursing personnel involved to meet patient s needs, promote recovery, ensure medical safety Management by skilled personnel of personal care services requiring technical intervention Management and evaluation of Patient Care Plan, cont d. Review the following: Written care plan and how their elements are reflected in ongoing medical assessment data Did the patient show psychological or mental impairments in addition to physical impairments? Was nursing intervention needed to ensure patient safety and promote recovery? Assess all services in light of patient s total condition Some non skilled services might require skilled management even if each service is non skilled Multiple medical diagnoses requiring extensive nursing services may support need for skilled management Observation and assessment of patient s changing or unstable condition Look at the records for the following skilled services: Medical necessity was documented by doctor s orders and nursing or therapy notes Skilled personnel were used to identify and evaluate the patient s needs Modification of treatment was needed for additional medical procedures Care was necessary until the patient s condition stabilized or to make sure the patient remained stable Reasonable probability existed of potential complication or acute episode which required monitoring by skilled personnel (even if no complication occurred) Acute psychological symptoms present in addition to physical problems

8 Patient education may be skilled service if technical or professional personnel needed to teach a patient self maintenance and management of treatment regimen Examples include: Teaching self-administration of injectible medications or complex range of medications Teaching a newly diagnosed diabetic to administer insulin injections, prepare/follow diabetic diet, and foot care precautions Gait training and teaching of prosthesis care for a recent leg amputee Teaching colostomy care Teaching patients the use and care of braces/splints/orthotics, etc Opinion of the attending physician Critical: opinion of attending or treating physician to be given special consideration One administrative ruling sets out four specific points: No presumptive weight may be given to opinion of treating physician in determining medical necessity of inpatient hospital or SNF services The treating doctor s opinion must be evaluated in context of all evidence in the record Treating physician certification is required for Medicare payment but coverage decisions are not based only on physician certification Coverage decisions are based on objective medical information available from claims forms and the medical record NOTE: if at ALJ stage, cross examine medical adviser (ie. Maximus doctor) to establish that doctor has not treated or examined the beneficiary, but has only reviewed the documentation. Restoration potential of the rehabilitation patient Key: rehabilitation services are skilled services, even if the services are in the form of maintenance therapy, if provided by skilled therapists many Maximus doctors get this wrong and say improvement and rehabilitation potential are the correct standards - From Medicare manual: the restoration potential of a patient is not the deciding factor in determining whether skilled services are needed; even if full recovery is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities - Despite this rule, Medicare coverage usually denied for those who reach plateau

9 Non-certified bed Must determine the SNF is a Medicare provider and the patient is in a Medicare certified bed If the patient is placed in a non-certified bed erroneously / inadvertently, payment by Medicare should be made