The federal government has implemented some key waivers designed to ease health care system burdens, including adopting a waiver of the requirement to have a three-day stay in a hospital to get Medicare coverage of a skilled nursing stay.
But some of those waivers have led to confusion among operators — and some of the potential pitfalls could get them into trouble, according to a Monday webinar hosted by the reimbursement consulting firm Zimmet Healthcare Services Group, based in Morganville, N.J.
The Centers for Medicare & Medicaid Services (CMS) issued several blanket 1135 waivers in the wake of the declaration of COVID-19 as a national emergency.
Among them are the temporary emergency coverage of Medicare Part A SNF benefits without a qualifying hospital stay for those who need to be transferred to a SNF because of a disaster or emergency — as well as the authorization of renewed SNF coverage without having to start a new benefit period for certain beneficiaries who recently exhausted their SNF benefits.
There appears to be significant confusion about the latter provision, however, Marc Zimmet, president and CEO of Zimmet Healthcare Services Group, said on the webinar.
SNF operators have to be careful of how they’re classifying patients because the waiver only applies to beneficiaries who were “delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances,” according to the text.
The question of when a benefit period for a patient ends is “age-old” and “frankly has not been administered very well by a great number of facilities out there,” Zimmet said. But under normal circumstances, in order to “break the spell of illness” — the same thing as a benefit period — a patient has to go for 60 consecutive days at a non-skilled level of care, he explained. They don’t begin because of a change in condition, diagnosis, or calendar year.
That’s where operators appear to be muddled, according to Zimmet.
“This waives that 60-day requirement for patients that are already on the road to custodial care, or on the road to breaking the spell of illness,” he said on the webinar. “That is the big disconnect. We’ve had operators calling up and saying: We’re going through our house, we’re putting every patient that’s skilled on program for another 100 days. [The waiver] is not a license to skill.”
If the patients, under normal circumstances, would never have been on the road to reaching a non-skilled level of care for 60 days, they cannot be added for another 100 Medicare days, he emphasized. The question is whether the emergency situation interrupted the patient’s path to 60 consecutive days of non-skilled, custodial care.
Another point to consider during the COVID-19 pandemic, which has swept the U.S. with cases rising dramatically from week to week and day to day, is that the mere difficulty of discharging a patient does not automatically mean continued Medicare Part A overage of a SNF stay, Zimmet added.
This is true even if a patient is afraid to return home, or cannot do so because of the COVID-19 emergency, he noted.
“While Medicare coverage would remain available through the Part B benefit, Medicare cannot pay for another Part A benefit period under that scenario, without [the patient] being at the [required] level of care,” he said. “Now, if they had used 100 days, and were about to go home because they were no longer skilled … and there was no safe discharge, that patient is on the road to the 60 consecutive non-skilled days. That would qualify them. But in order to put them back on, they would need the return to clinical eligibility.”