Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted post-payment review of claims for Medicare Part A Skilled Nursing Facility billed on dates of service from March 1, 2020 through December 31, 2021. Below are the review results:

Background

Prior to the COVID-19 pandemic and subsequent Public Health Emergency (PHE), qualification for post-hospital extended care services, including SNF care, required the beneficiary to have a medically necessary hospital stay of at least three consecutive calendar days prior to SNF admission per the Medicare Benefit Policy Manual, Publication 100-02, Chapter 8, Section 20. In response to the PHE, CMS, using authority under Section 1812(f) of the SSA, waived the requirement for a 3-day prior hospitalization for coverage of a SNF stay. This waiver provides for coverage of a SNF stay, without a three day qualifying hospital stay (QHS) during the PHE.

Data analysis done by CMS and the SMRC identified a potential area of vulnerability.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record review on SNF claims that had zero hospital days prior to the SNF admissions with dates of service March 1, 2020, through December 31, 2021. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• No response to the documentation request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Documenation did not support claim as billed
  • CMS Internet-Only Manual Pub 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4, Pub 100-04 Medicare Claims Processing Manual, Chapter 23.) The documentation submitted was insuffient to support the Health Insurance Prospective Payment System (HIPPS) code billed on the claim.
• Doumentation did not include certification or recertification
  • Medicare Benefit Policy Manual IOM 100-02, Chapter 15, Section 220.1.3. Certification or recertification were not submitted for review.

References

Social Security Act (SSA), Title XVII

• § 1812(a)(2)(A) Scope of Benefits
• § 1813(3) Deductibles and Coinsurance
• § 1814(2)(B) Conditions of Payment and Limitations on Payment for Services
• § 1815 Payment to Provider of Services
• § 1819(a)-(d) and (f) Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities
• § 1833(e) Payment of Benefits
• § 1861(a), (h)-(j) Definitions of Services, Institutions, Etc.
• § 1862(a)(1)(A) Reasonable and Necessary
• § 1862(a)(20) Exclusions from Coverage and Medicare as Secondary Payer
• § 1879(a) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• § 1888(e) Prospective Payment
• § 1888(g) Skilled Nursing Facility Readmission Measure
• § 1888(h) Skilled Nursing Facility Value-Based Purchasing Program
• § 1893(b) Medicare Integrity Program
• § 1899(f) Waiver Authority

42 Code of Federal Regulations (CFR)

• § 409.30-409.36 Requirements for Coverage of Posthospital SNF Care
• § 410.12 Medical and other health services: Basic conditions and limitations
• § 411.15(k)(1) Particular Services Excluded from coverage
• § 411.15(p) Services Furnished to SNF Residents
• § 411.4 Payment for custodial care and services not reasonable and necessary
• Subpart A, § 413.1 Introduction and General Rules
• Subpart J, § 413.330 Basis and Scope
• Subpart J, § 413.333 Definitions
• Subpart J, § 413.335 Basis of Payment
• § 413.343 Resident Assessment Data
• § 413.360 Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
• § 424.20 Requirements for Posthospital SNF Care
• § 424.5(a)(6) Sufficient Information
• § 425.612 Waivers of payment rules or other Medicare requirements
• § 483.315 Specification of Resident Assessment Instrument

Federal Register

• Interim Final Rule with Comments (IFC), CMS-1744-IFC. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. Effective March 1, 2020. Retrieved from CMS-1744-IFC
• IFC, CMS-5531-IFC. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. Effective March 1, 2020. CMS-55341-IFC

Balanced Budget Act of 1997 (BBA), Public Law 105-33

• § 4432(b) Prospective Payment for Skilled Nursing Facility Services

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Chapter (Ch.) 8 § 10 Requirements General
• Ch. 8 § 20 Prior Hospitalization and Transfer Requirements
• Ch. 8 Coverage of Extended Care (SNF) Services Under Hospital Insurance
• Ch. 8 § 30 Skilled Nursing Facility Level of Care General
• Ch. 8 § 40 Physician Certification and Recertification of Extended Care Services
• Ch. 8 § 70 Medical and Other Health Services Furnished to SNF Patients
• Ch. 15 § 250 Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities
• Ch. 16 § 20 Services Not Reasonable and Necessary
• Ch. 16 § 110 Custodial Care

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 1 General Billing Requirements
• Ch. 6 SNF Inpatient Part A Billing and SNF Consolidated Billing
• Ch. 6 § 30 Billing SNF PPS Services
• Ch. 6 § 100 Part A SNF PPS for Hospital Swing Bed Facilities
• Ch. 6 § 120 Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
• Ch. 30 Financial Liability Protections
• Ch. 30 § 40 and 50 Advance Beneficiary Notice of Non-coverage (ABN)
• Ch. 30 § 130.2 A Three-Day Prior Hospitalization

IOM, Medicare Program Integrity Manual Publication (MPIM), Pub. 100-08

• Ch. 3 § 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 3 § 3.2.3.2 Time Frames for Submission
• Ch. 3 § 3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3 § 3.2.3.8 No Response or Insufficient Response to Additional Documentation
• Ch. 3 § 3.3.2.1 Documents on Which to Base a Determination
• Ch. 3 § 3.3.2.4 Signature Requirements
• Ch. 3 § 3.3.3 Reviewing Claims in the Absence of Polices and Guidelines
• Ch. 3 § 3.6.2.2 Reasonable & Necessary Criteria
• Ch. 6 § 6 Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
• Ch. 6 § 6.3 Medical Review of Certification and Recertification of Residents in SNFs

Local Coverage Determination (LCD)

• L35008 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)
• L36219 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)

Local Coverage Article (LCA)

• A55503 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015
• A55505 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015

Other

• Minimum Data Set Manual, CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.17.1, Effective October 2019
• Medicare Learning Network (MLN) SE18026 November 2018. New Medicare Webpage on Patient Driven Payment Model
• Medicare Learning Network (MLN) ICN MLN006846 December 2018. SNF Billing Reference
• Medicare Learning Network (MLN) ICN 9730256 April 2021. Skilled Nursing Facility 3-Day Rule Billing
• Medicare Learning Network (MLN) SE20011 September 2021. Medicare FFS Response to the PHE on COVID-19

Last Updated Mar 14, 2023