Denial of Medicare Non-Payment of New Admissions

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.