Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
In the quest for accurate and appropriate reimbursement the industry is faced with complex tasks including ARD Selection, Minute Management and ADL Coding, to name a few. The Harmony Healthcare International (HHI) Team has a message for all of you:
“Get back to Basics.”
The insurgence of new staff coupled with the additional regulations set the stage for distraction and simple errors. There is a notable rise of the HarmonyHelp calls we receive requesting clarification on the conditions in which a beneficiary meets the 60 Day Spell of Wellness, i.e., when a patient is eligible for another benefit period under the Medicare Part A insurance program. The Harmony Healthcare International (HHI) Team suggests a weekly review of the Medicare Days for all current beneficiaries as well as all beneficiaries denied Medicare Part A Benefits within the last 30 days.
These situations require careful, case by case review to ensure that benefits are accurately utilized and coincide with the common working file. Beneficiaries may not access their full 100-day benefit period, or “exhaust” benefits, when their level of care no longer meets clinical requirements for skilled care. The beneficiary may re-access Medicare Part A benefits in specific situations. For Example:
- Within a 30 Day Time Frame of denial from Medicare Part A benefits, if a beneficiary is identified by the Clinical Team to have a change in their level of care that meet the clinical requirements for daily skilled care, the beneficiary may re-access the remainder of their 100-day benefit without requiring additional qualifying hospital stay. The patient must require skilled care for a condition that was treated while the patient was hospitalized or which arose secondary to being in the skilled nursing facility following the hospitalization. The classic example would be a patient who is admitted to the SNF for post-acute care and subsequently develops pneumonia while in the SNF. Harmony Healthcare International (HHI) recommends that there is a clear connection between the skilled condition and the treatment of that condition in the hospital evident in the medical record.
- A second scenario occurs when the beneficiary on the skilled unit concludes skilled services, yet has days reminding the benefit period. The patient becomes ill again after the 30-day window has passed, but prior to the completion of the 60-day spell of wellness. In this case, the patient may reengage the remainder of their 100-day benefit, provided they have a new three-day qualifying hospital stay. This new inpatient hospital stay can be for a new clinical problem.
Providers should be aware that this second inpatient admission into the hospital would stop the clock on the 60-day spell of wellness. The patient will have to return to a non-skilled level of care to begin the count for the 60-day spell of wellness period, and the count for the 60-day spell of wellness start over at day one. This full and uninterrupted 60-day spell of wellness period will be required before the beneficiary can become entitled to a new 100-day benefit.
An emergency room visit without an admission to the hospital will not interrupt the 60-day spell of wellness count. Also, it does not act as a qualifying inpatient hospital stay. Therefore, the patient would not be allowed to access the remainder of the 100-day benefit based on an emergency room or non-inpatient hospital stay.
Harmony Healthcare International (HHI) recommends that Providers maintain a careful count of all non-skilled days to accurately identify when the beneficiary is entitled to a new 100-day benefit. Providers are reminded that access to a benefit period is a technical requirement for Medicare coverage. If a beneficiary does not meet technical requirements for Medicare coverage, there is not avenue for appeal. It is the responsibility of the SNF to ensure technical requirements for Medicare coverage are satisfied before engaging the Medicare benefit.
Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here. Looking to train your staff? Join us in person at one of our our upcoming Competency/Certification Courses. Click here to see the dates and locations.
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