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Did you know that CMS allows Medicare Advantage plans a waiver for the 3-overnight rule for SNF placement? Many Medicare Advantage plans utilize this benefit and will allow patients with a skilled need to be authorized for a SNF admission and gain access to their Medicare A benefits. 

What does this mean for you? As a SNF service provider, you must verify benefits for Medicare Advantage members prior to admission. When you are completing verification, be sure to ask if a 3-overnight stay is required. If you are told no, then you can proceed to requesting authorization.

Working with hospital emergency rooms or physician’s offices can be easier if you know the waiver rule as well. It is a big win when you are known as the SNF that educates the ER and works with them to admit from the ER or the physician’s office to the facility.  Admissions from the ER or a physician office require documentation similar to that of an admission from home: most current H&P, physician order, med lists and documentation supporting the skilled need. This documentation provides the reasoning why a lower level of care is not sufficient for the patient. 

This also means that if you have a long -term care resident who has a Medicare Advantage plan and acquires a new skilled need (i.e.; IV antibiotics q8 for pneumonia), you can request a skilled authorization for that patient’s care in house with no need for hospitalization. Please note that the 60-day wellness break still applies and the patient must have Medicare A days available.

All health plans require their providers to be in good standing with the State and CMS. However, there are times when a facility may be outside the standard compliance requirements. Health plans require facilities to notify them of this non-compliance.  
 
SNF’s may experience a Denial of Medicare Non-Payment of New Admissions (DPNA) as a result of a failed survey process. When a facility receives a DPNA, health plans may determine that the facility cannot receive new admissions until cleared by CMS. This is counter to what CMS will allow; CMS will allow a facility to continue admitting patients but the facility is at risk for nonpayment if the citations are not cleared within the timeframe indicated.  Once all citations are cleared (within the designated timeframe), CMS will release payments dating back to the citation date.  Health plans, however, see this differently and will often deny admissions upon their knowledge of the DPNA. Health plans are allowed, per CMS, to determine their guidelines for participation as well as their own processes.  Once a facility timely clears the sanctions/citations, the plan will generally lift the ‘Do not admit’ policy and should pay any outstanding associated claims.  
 
Here is sample language from one health plan regarding on-going monitoring of compliance: “Practitioners identified with state licensure sanction that does not remove licensure are requested to provide full information to the Health Plan and the information is then reviewed by the Medical Director and/or the Credentialing Committee for acceptance.”
 
If your facility has received sanctions, it is appropriate to send notice of such sanction directly to the health plan and/or to your managed care consultant team for review.  

Doing a formal appeal is always the last step when working on a claim. Before filing an appeal, it is highly recommended that all other avenues be exhausted such as calling claims to determine why the claim denied, determine if a corrected claim needs to be submitted or reprocessing will take care of the issue, just to name a few. If it is determined that a formal appeal is needed, be sure to do it thoroughly and correctly as you may only have one chance; BCBS and Aetna only give one opportunity. Be sure to use the appropriate form provided by the plan. Clearly understand their process. Is this an administrative appeal or is it a clinical appeal? What is your window for filing the appeal? Don’t let it time out.

If you are in doubt of the process or how to work the claim, call your Managed Care Liaison for assistance, they will be glad to help!

Every player in the acute and post-acute care continuum are focused on reducing Return To Hospitals (RTH) rates. Not only does RTH impact the resident in a negative manner, but it also impacts the provider with poor client ratings and now possibly financial penalties. While Medicare has been leading the way in this area, the Managed Care/Insurance plans are also heavily focused on this subject. SNFs have better control while the patient is in the facility, but what about post discharge? What can SNFs do better to reduce the RTH rate after they left our care.

Consider engaging the Primary Care Physician (PCP) in the community upon their patient admission. By contacting the PCP, you are opening conversations regarding patient care, alerting them that the patient was in the hospital and now in SNF. Often the PCP is not aware of the patient’s change of condition and situation. During this communication, you could also attain their preferred Home Health Agency and who to speak to regarding potential referrals for outside services. This information will also help your team during the stay as well as upon discharge.

Upon discharge of the patient, providing the DC summary and medication reconciliation to the PCP will also assist in the preventing a RTH. A high percentage of RTH issues are related to medication errors. While home health does do this activity, it is important to close the loop with the PCP as well. In addition, partnering with home health agencies to communicate back to the SNF about patient issues will provide opportunity to readmit the patient to SNF (as appropriate) and divert from the ER. Following up with these entities will help with continuity of care and will result in additional referrals by being a good partner. Addressing the full continuum helps to treat the patient as a whole as opposed to just treating the patient for their admitting diagnosis.