Harmony Healthcare Blog

The Medicare Spell of Illness (Benefit Period)

Posted by Sally Fecto on Thu, Apr 13, 2017

C.A.R.E.

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


backtobasics.jpgThese past few weeks of on-site audits with the Harmony Team continue to reinforce the need for everyone to get back to basics.  All of the hype and frenzy over payment reform is distracting and disrupting the focus on the simplest of tasks.   What task you ask?  Spell of Illness. 

In order to successfully operate in the Skilled Nursing Facility space, Kris Mastrangelo continually messages these 3 focal points:

  • Fill Your Beds
  • Collect your Money
  • Provide Quality Care 

Sometimes, filling the beds means managing the back door.  How you ask?  Review all patients who have ended their Medicare Part A benefit due to exhaustion of days or lack of daily skilled services within the last 30 days

30-Day Window 

The 30-Day Window affords the beneficiary the ability to re-access benefits without another qualifying hospital stay, for skilled care for conditions treated during the qualifying stay or arose while on skilled coverage. It is prudent to discuss all patients (within the facility), denied coverage within the last 30 days.  A review of the patient’s status with the nurses overseeing the patients plan of care is essential.  That’s right, invite these nurses to the Medicare Meeting. You might be surprised to find out that the patient requires a reactivation of his or her Medicare Part A Benefit.

60-Day Break 

Each patient should be discussed in detail to determine if there is a daily skilled need or if the patient remains at a non-skilled level of care for the count towards the 60-Day Break (“period of wellness”) which provides eligibility for another benefit period. 

If a 60-day period of consecutive days of non-skilled level of care is met, the beneficiary will generate another 100-day benefit regardless of the number of days left on the prior benefit period. (However, a 3-night hospitalization is required to initiate the new spell). 

It is important to monitor the patient who exhausts their 100-day benefit to identify when and if the patient experiences a decrease in skilled level of care i.e., no longer requires the daily skills, knowledge and judgment of a nurse or therapist and the treatment regimen has essentially stabilized.  The team must identify the first day of non-skilled level of care.  This process is well suited for incorporation into the Medicare Meeting. 

No-Pay and Benefits Exhaust Bill 

Reporting of the above dates to billing is critical for correct billing submission and to update the Common Working File.  If the patient maintains the skilled level of care, for example, a G-Tube Dependent patient receiving total fluids and nutrition via the feeding tube, the patient will not break the skilled level of care.  A no-pay bill is submitted monthly to update the Common Working File. 

An SNF is required to submit a bill even though no benefits are paid by Medicare.  CMS maintains a record of all inpatient services for each beneficiary, whether those services are covered by Medicare or not. The information is enables CMS to keep track of the beneficiary’s benefit period.  These bills are required in two situations: 

  • When the beneficiary has exhausted their 100 covered days under the Medicare SNF benefit (benefits exhaust bills); and
  • When the beneficiary no longer requires a Medicare covered skilled level of care (no-payment bills). 

In the case of Benefits Exhaust, the SNF submits a monthly bill for the patients that continue at a daily skilled level of care and when there is a change in the level of care. 

Do you understand Spell of Illness?  Take this quick quiz and see how you do:

Days Used Break Hospital Stay Day On?
55 65 days no skill 4  
44 50 days no skill 4  
48 25 days no skill 0  
100 G-Tube  62 days no skill 25  
100 G-Tube  65 days skilled care provided 25  

 

Click Below to Download Answer Sheet.

Download Your Quiz Answers

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have regarding Medicare Spell of Illness, you can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming CompetencyCertification Courses (CHHi-CP).  Click here to see the dates and locations.


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Tags: Medicare, Spell of Illness

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