SNF Demand Review Interim Findings

The Social Security Act requires CMS to ensure payment is made only for those medical services that are medically reasonable and necessary. CMS mandates review of Skilled Nursing Facility (SNF) Demand claims. The purpose of this update is to inform providers of recent findings with the review of SNF Demand claims.

Summary of Findings

Findings of the 3 claims reviewed from October 1, 2020 through December 31, 2020 are as follows:

  • 1 claim was denied in full with provider liability for the following reason:
    • The Skilled Nursing Facility Notice of Non-coverage (SNFABN) provided was invalid.
  • 2 claims were denied in full with beneficiary liability for the following reasons:
    • Nursing services were custodial in nature
    • No skilled service provided

The overall error rate for this service specific targeted review is 5.4%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice, although this will not affect the error rate of the pre-payment review.

Education

Topic Details
Skilled Nursing Facility Notice of Non-coverage (SNFABN)

An advanced beneficiary notice (ABN) is a written notice of Medicare denial of payment and must contain sufficient information to enable the beneficiary or authorized representative to understand the basis for the denial. In order for a SNF to transfer liability to a beneficiary for items or services paid under Medicare Part A, the SNF must issue a SNF ABN for an item or service that may not be paid for by Medicare due to not being medically reasonable and necessary or custodial care. Such notice must be given to the beneficiary timely, before he or she receives specified items or services that otherwise might be paid for so that the beneficiary has time to make other arrangements.

The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. For additional SNF ABN information, refer to the Medicare Claims Processing Manual (MCPM) Chapter 30 section 70.

Completing the SNFABN

Please refer to the SNFABN and instructions which are located on the CMS FFS SNF ABN webpage. The SNFABN has the following 5 sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question.

The Header must include SNF information including SNF name, address, and phone number, at a minimum. The header must also include the patient's name. Patient identification number is optional.

The Body must include the "beginning on…," date which the beneficiary may be responsible for payment. The Care, Reason Medicare May Not Pay, and Estimated Cost sections must also be completed in the Body.

In the Option Boxes section, there are three options with corresponding checkboxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary.  Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice.

SNFs may use the Additional Information section to clarify and/or provide additional information they think might be helpful to the beneficiary.

The Signature and Date section must be signed by the beneficiary or their authorized representative to acknowledge s/he understood the notice. The SNF may fill in the date if the beneficiary requires assistance. This date should reflect the date that the SNF gave the notice to the beneficiary in-person, or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for the beneficiary, write "(rep)" or "(representative)" next to the signature. If the beneficiary refuses to choose an option and/or refuses to sign the SNFABN when required, the SNF should annotate the original copy of the SNFABN indicating the refusal to sign and may list a witness to the refusal.

Coverage Criteria

In order for a Beneficiary to receive coverage in a skilled nursing facility (SNF), the following criteria must be met:

  • The beneficiary must be entitled to receive Medicare Part A
  • There must be a medically necessary 3-day qualifying hospital stay
  • Transfer or admission to the SNF must occur within 30 days at a skilled level of care
  • Benefit days must be available to the beneficiary
  • The patient requires skilled nursing services or skilled rehabilitation services, i.e.:
    • Services must be performed by or under the supervision of professional or technical personnel (see section 30.2 - 30.4)
    • Services must be ordered by a physician and rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services.
  • The patient requires these skilled services on a daily basis (see section 30.6) and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (see section 30.7.)
  • The services must be reasonable and necessary for the treatment of a patient's illness or injury, i.e.:
    • Being consistent with the nature and severity of the individual's illness or injury, the individual's particular medical needs, and accepted standards of medical practice.
    • The services must also be reasonable in terms of duration and quantity.
  • The patient must be admitted to a SNF within 30-days of discharge from a hospital and require skilled care. (See exception to this criteria)
If any one of these factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.
SNF Skilled Care Factors

Skilled care in a SNF is covered if all of the following factors are met:

  • An inpatient stay is required.
  • A physician's order is in place and the patient requires skilled nursing services or skilled rehabilitation services on a daily basis.
  • Services must be performed by or under the supervision of skilled nursing or rehabilitation professionals.
  • Services need to be reasonable and necessary for the treatment of the patient's illness or injury.
Skilled nursing services or skilled rehabilitation (or a combination) must be needed and provided on a "daily basis," seven days a week. If skilled rehabilitation were not available seven days a week, a patient, whose inpatient stay is based solely on the need for the skilled rehabilitation would meet the "daily basis" requirement if they are provided at least five days a week.

 

References

View SNF references used in review. Further educational opportunities may be found under Education & Outreach. Individual education may also be requested from the Provider Outreach and Education staff via the External Provider Outreach & Education Request Form.

Provider Action Required

Providers should review individual claim determinations by checking page 4 of the claim in DDE to view medical review comments and determinations. Instructions on locating medical review comments are detailed in the article Access Medically Reviewed Claim Determinations in DDE .

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports that skilled services were provided.
  • Verify ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.
  • Review minimum requirements for SNFABN

Summary

Medical Review of SNF Demand claims are mandated by CMS; therefore Noridian will continue this review.

If you would like to receive information regarding findings specific to your facility, send an email to myresults@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for file number S1308-000.
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • Provider number (Include provider's six digit Provider Transaction Access Number (PTAN), do not include National Provider Identified (NPI)
    • Method of how you would like to receive results: Phone call, fax or U.S. mail. Include fax number or mailing address, if applicable. "My Results" contain beneficiary and claim specific information and will not be sent via email.

Upon request receipt, Noridian Medical Review will respond as timely as possible. A letter will be sent to your facility detailed specific facility claims findings. Requests may take up to two weeks to be completed.

If you have any other questions, contact the Provider Contact Center.

 

Last Updated Thu, 14 Jan 2021 13:52:47 +0000