Harmony Healthcare Blog

ICYMI - More Questions and Answers: ABN and NOMNC

Posted by Sally Fecto on Tue, Aug 21, 2018


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Young business man in suit presenting hand drawn question marksThese questions come from our latest webinar on ABN and NOMNC.
Missed it? You can view it on-demand and download the handouts by clicking here.

  1. Question: Can you clarify about ABNs and outpatient service provided by a therapy company at an SNF? Not Part B for inpatients, but for outpatients who come to facility office for therapy.  Who is responsible for ABN, the facility or the therapy company?

    Answer: Outpatient services that are not under Medicare Part B- per the question.  They wouldn’t be under Medicare Part A.  I therefore assume under a health plan or commercial insurance plan.  It that’s the case, there is no ABN to be delivered.  The ABN is provided when the therapist believes that Medicare will not pay for the services to afford the patient opportunity to make an informed decision on cost/care. Addressing the distinction of whether the therapy company or SNF would provide an ABN for therapy:  it’s the provider who is ultimately responsible for notice.  Who is billing Medicare.  They are responsible.  
  1. Question: If a beneficiary has a Medicare advantage plan, and he is being covered under Medicare Part B, is a NOMNC required? (such as with a beneficiary who has traditional Medicare with Part B services stopping) ...... and furthermore, would a SNF ABN be required under the above condition (such as the requirement for traditional Medicare if the rp wishes to pay pp for Part B services)

    Answer: The NOMNC is required for all Medicare products:  Medicare Part A, Medicare Part B and Medicare Part C, also known as Medicare Advantage or a Medicare Replacement product.  The Medicare Advantage patient would be using Part B under that package and the NOMNC is required. 

    The SNF ABN is not required for Medicare Advantage plans, only traditional Fee for Service Medicare A/B. 
  1. Question: What about for Med B evaluation only for rehab and no further skilled treatment is necessary after the evaluation and 1 treatment? and the rehab order is 1x/wk. for 1 wk. only under Med B?  and the PT/POA agrees to 1 eval/tx only do we still have to give the ABN/NOMNC for Med B?

    Answer: In our opinion, the evaluation is a onetime order.  There are no treatment orders, a treatment plan or treatment provided.  The NOMNC is to identify that treatment will end and, in this scenario, there are no services ordered, provided or ending.  
  1. Question: I find out about hospice election but don't have a 2-day notice for delivery of NOMNC, the person is not dually eligible for Part A and Hospice, what is the LCD that should be entered on the NOMNC?

    Answer: Enter the effective date that the patient will be responsible, the first non-covered day.  There may be times where the 2-day notice is not possible as in the case where the patient elects to end Part A and elects Hospice benefit.  technically, if patient is electing to end Medicare the NOMNC is not required. 
  1. Question: Is NOMNC required for Med B - outpatients for therapy?

    Answer: Yes, NOMNC is provided to beneficiaries and/ or enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services.  The (CORF) is a medical facility that provides outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of injury, disability, or illness. CORF care is commonly known as outpatient rehabilitation care. 
  1. Question: Do you still give the NOMNC with the SNF ABN if a SNF resident chooses hospice immediately-unable to give a 48-hour notice?

    Answer: In this scenario, the patient is driving the end of coverage under Med A for the hospice election.  The SNF ABN is important as it will identify the financial liability as often the patient comes off Part A to go to routine hospice and responsible for room and board.  The Hospice GIP benefit is brief and not all facilities can offer this higher.  The lack of 2-day notice is OK as the patient make the determination and was not cut from coverage by facility.  The NOMNC is not required if the patient made the decision versus the facility ending coverage then going to hospice.  In the case of the later, the NOMNC is needed. 
  1. Question: Thank you for this training. Can you clarify, patient resides in facility, Therapy orders received, and patient qualifies for Medicare Part B. Pending DC from therapy, are NOMNC (48 hours) and ABN due?

    Answer: The NOMNC is required 2 days before the end of therapy.  The ABN is only used to communicate ongoing treatment the patient may request, and Medicare will likely not cover.  The ABN would be provided timely to give the patient information needed to make the financial decision.  If they receive the NOMNC and are in full agreement to end therapy, there are no financial concerns or need for ABN. 
  1. Question: What if the POA for a LTC SNF resident who's under Med B NOMNC agrees with the d/c and given 48 hours’ notice and documented on the letter that family agrees verbally but unable to sign immediately and requests to sign it when they come to visit in the future? Is that ok?  The date signed will not be before the d/c because they come to visit after that.

    Answer: When delivering any notice telephonically, such as the NOMNC, document in detail: 

    Who the notice was provided, phone number, date and time, appeals rights and anything else pertinent.  Best practice:  Mail the NOMNC certified, return receipt request.  Ask the family member to sign and bring back or mail back.  This will establish a valid time line in using the postal documentation on delivery or receipt.  There have been instances in which a family member later states they were not notified.  The postal documentation is critical.    
  1. Question: Do we give Med B ABN for every patient coming OFF therapy?

    Answer: No, only if they want more therapy that is not covered by Medicare B.  Give the NOMNC all times for traditional Medicare A/B/C.
  2. Question: Say we issue a notice on 7/12 to be effective 7/15. Resident appeals to the QIO on 7/15. QIO denies appeal on 7/17 and resident discharges home on 7/18. We continue skilled services beyond our initial end date as indicated on the notice, while waiting on the QIO decision. Can we bill through the date of discharge since we were required to continue services while waiting on the appeal decision?

    Answer: No, once you determine that patient is no longer skilled, you cannot bill Medicare.  Therefore, the SNF ABN is critical to identify the cost of care should their appeal be declined. The SNF ABN will identify the skilled services and allow the patient to make the financial decision to continue this care and the financial impact should they continue to receive the services and lose the appeal.  We would not bill Medicare for those days. The patient is liable if given proper liability notice.
  3. Question: Please clarify when ABN should be given for Medicare Part B. We are doing it 48 hours before end of therapy as we are not sure as to the amount of services unless the patient has been evaluated and had some tx already.

    Answer:
    NOMNC is provided 2 days before end of therapy.

    ABN is provided only if the patient wants to continue, initiate or increase therapy that is deemed not medically necessary and Medicare likely not to pay.
  4. Question: So, if we have a physician order for therapy and its medically necessary, we don’t need to give Med B ABN?

    Answer: Correct, if the patient meets Medicare coverage criteria.
  5. Question: Do you have to give an ABN to a resident going on Hospice if they are not terminally ill?

    Answer: Unclear on specifics.  If patient goes on hospice services, there must be criteria met and certified by the hospice medical director.  If that level changes, notices are the responsibility of the hospice provider.
  6. Question: Will ST alone skill a patient?

    Answer: Yes, if the service is provided 5 days per week.  Highly recommend nursing to continue to assess and document the reason why the patient continues to need speech therapy and its relationship to the hospital stay or condition that arose while skilled.  Anchor always with nursing documentation. 
  7. Question: If a resident is covered under Medicare A and admits to hospice unexpectedly (meaning not with a 2-day notice), is the NOMNC still needed? Facility is not saying that resident no longer meets skilled criteria, resident is electing to come off skilled services.

    Answer: It sounds like the facility made the determination of non-skilled level of care and as a result the patient has elected hospice.  Give the NOMNC and the SNF ABN.
  8. Question: Can you please explain why we are issuing an ABN (if MCR days remain) and patient remains in facility, electing Hospice Care? The patient is electing to discontinue therapies/skilled care in order to pursue Hospice, so no NOMNC but ABN?

    Answer: You are correct in that the patient is electing to end Part A coverage and transition to Hospice.  NOMNC is technically not required.  Many providers deliver to avoid confusion with all the issues that can arise with beneficiary notification. 

    The SNF ABN (not the ABN - very different) is given as the financial responsibility and liability now shifts to the patient. Not all hospice patients have room and board covered if under routine hospice benefit.  they are responsible for the daily rate. The SNF ABN clearly defines and notifies in advance of financial liabilities.
  9. Question: My NOMNC question is regarding a true outpatient - non-resident of SNF. Is NOMNC required for non-resident OP?

    Answer: Under Medicare Products in a CORF, yes.
  10. Question: If resident experiences a qualified stay, but refuses to use her Medicare Part A services what letter do you use?

    Answer: SNF ABN detailing financial liability because technical eligibility is present.
  11. Question: Patient decides to go hospice and is on Medicare A. Which letters to give?

    Answer: Required:  SNF ABN. 

    Technically, NOMNC is not required when the beneficiary makes the decision to end coverage.  It is important patient and family clearly understand the financial liability associated with ending Med A and electing hospice.  GIP covers room and board but rare and of a very short duration. Likely patient will be responsible for room and board and needs to know prior to receiving care.
  12. Question: Do I understand correctly that the SNF does NOT need to give the Medicare part B patient ABN?

    Answer: There are 3 triggering events:  initiation of services believed not to be medically necessary, reduction of services when the patient wants more- not medically necessary, termination of services only if the patient wants more services that are identified as not reasonable or necessary and likely not covered under Part B.
  13. Question: Niece (non-guardian) calls in QIO but resident keeps refusing Therapy. And QIO favors the Niece?

    Answer: Niece does not need to be guardian.  Patient may defer this responsibility to another induvial.  Need more details re: Part A or Part B, frequency of orders, review treatment plan, etc.
  14. Question: Patient had a psych stay for 3 weeks. Is notice given on return. MCR not paying for psych.

    Answer: Medicare does not deny psych, in general terms.  Interested in details of the case.  Technically eligible, returns and deemed not skilled by facility = deliver SNF ABN.  No NOMNC because Medicare did not cover.  The SNF ABN allows for demand billing with the MAC.
  15. Question: Many providers discharge the first non-covered day, although, there are different thoughts on why a facility will wait to discharge on the first non-covered day. Even though the day of discharge is not billed, why wouldn't the Medicare stay be through the day the resident leaves the facility? Shouldn't the SNF-ABN be issued if the last covered day is the day before discharge?

    Answer: It is not a bad idea to issue in the event the patient is not discharged.  Example. NOMNC given on Thursday with LCD of Saturday.  Expectation patient will discharge on Sunday (non-billable).  You return from the weekend to find the patient did not discharge due to non-clinical reasons?  Would recommend for weekends, just in case.  Wouldn’t do routinely if the patient agrees and planning to discharge.  Any changes likely due to medical and may result in rescinding the NOMNC for ongoing skilled (in some instances).
  16. Question: We were told that if someone discharges from Managed Medicare directly to Hospice care, and NOMNC is not needed. Is this true?

    Answer: Under FFS, one would give the SNF ABN.  This is a Managed Medicare Plan.  If patient elects end of coverage, no NOMNC required.  Many patients receive hospice under the outpatient home care level and responsible for the daily cost in the nursing facility. Some providers give to overcommunicate versus under communicate.
  17. Question: After a 3 days refusal - we have to dc according to Medicare- how to skill through day 8?

    Answer: Presumption of Coverage; if the patient receives care and it is accurately coded on the MDS and yields an upper RUG Level, Medicare will cover through the ARD of the 5-day MDS.  I would have to ask about the medical status of the patient and reason for refusal.  Nursing should anchor coverage and typically are providing skilled observation, assessment, intervention, management of care plan during this time.  Combination of skill with nursing and rehab.
  18. Question: Can you provide a summary of the 3 options are that the beneficiary can select

    Answer:
    • Option 1: resident wants to continue to receive care in the SNF and wants Medicare to review the case. The provider must submit a demand bill to the Medicare Admin Contractor (MAC)
    • Option 2: resident wants to continue to receive care in the SNF but does not want Medicare to review the case and agrees to be financially liable.
    • Option 3: resident chooses not to continue to receive further items or services in the SNF and would be discharged.
  19. Question:  A resident on Part B skilled therapy 3 days per week refused care for three days consecutively, was warned could not continue to receive skilled care if continues to refuse... Do we issue the letter? 

    Answer: One must ask why they are refusing.  If they no longer want therapy, then then are electing to end services.  Technically, no notice required but need an effective way to communicate this patient driven decision. 

    Would also ask:  after finding out why the refusal, would change in order frequency or plan help?  Will the patient benefit from visits over a period?  Resident centered.  10 visits in 4 weeks.  We need to be flexible to meet the needs of the patient.
  20. Question: The MA plan is required to issue the SNF-ABN. The facility is required to issue appeal rights (NOMNC). If agreed in the MA plan contract or agreement, that the facility will issue notice, then the facility is responsible for the ABN.  

    Answer: Medicare Replacement Plans must issue NOMNC.  The SNF ABN is not provided to Managed Medicare Plans. MA plans are not required to use SNF ABN, only NOMNC and often ask the SNF to deliver it and send them a copy.  Make sure to have the Plan info accurate on the NOMNC so that the QIO can contact the plan should there be a request for expedited appeal.
  21. Question: We are aware that we do not to issue any notice if the resident exhausts their 100 days. If the patient stays in the facility can we issue the NOMNC or ABN to be used for TAR by the business office?

    Answer: Benefits exhaust do not require notice. You may use the SNF ABN in a voluntary manner to communicate or you may use a form designed by facility with policy for documentation purposes.
  22. Question: What is considered a reasonable estimated cost?

    Answer: For the SNF ABN:  Daily Rate.  For example: 
    • Care: inpatient stay as this nursing facility.
    • Reasons Medicare May not pay: you do not require daily skilled care.  Medicare will only pay for daily skilled care.
    • Cost: $300.00 /day.

      For ABN:  Estimate of the services by the CPT/HCPCS.
  23. Question: Should we give the ABN before start of rehab eval/tx?

    Answer: No, only if you believe that the services will not be covered by Medicare. 
  24. Question: Will you have education on CBD legal marijuana?

    Answer: Yes. In the fall.
  25. Question: If a patient admits to a facility who is not skilled do they need a NOMNC letter issued before admission?

    Answer: The NOMNC is not required if the patient is not technically eligible (no qualifying stay, no days).  Give the SNF ABN on admission when they are technically eligible but not at a skilled level. This allows the patient to request a demand bill by the MAC.  The SNF ABN may be used on a voluntary basis without signature or options elected.  Suggest facility policy to define process.
  26. Question: What if they don’t want to choose a box?

    Answer: You need to ask them and may check under their directions.  You cannot decide for the patient.  Describe in basis terms: 
    • Option 1: resident wants to continue to receive care in the SNF and wants Medicare to review the case. The provider must submit a demand bill to the Medicare Admin Contractor (MAC).
    • Option 2: resident wants to continue to receive care in the SNF but does not want Medicare to review the case and agrees to be financially liable.
    • Option 3: resident chooses not to continue to receive further items or services in the SNF and would be discharged. 

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