Ask the payment expert ... about the observation stay loophole

We were told we didn’t meet technical requirements for Medicare. What does that mean?

Technical requirements must be met to be paid by Medicare. Two examples are certifications/recertifications and giving a notice of non-coverage prior to discharge. 

If these and other technical requirements are not met, your Medicare claim will be denied. Further, you cannot appeal a denial based on technical requirements not being met. 

First, certification/recertifications.  In order for a resident to be covered by Medicare, a physician/nurse practitioner/physician assistant must certify that the resident needs skilled care in the facility, and that the care is related to the hospital stay.

Most fiscal intermediaries (FIs) and Medicare administrative contractors (MACs) look for this to be completed within a few days of admission. Check with your FI/MAC about requirements. 

Then, the rule states that a recertification must be obtained within 14 days and every 30 days thereafter. This recertification must identify what skilled services are needed. The initial recertification can be completed with the initial certification and then your next certification is not due for 30 days. 

Remember that the 30 days starts on the day the physician signs the first recertification. 

Second, the notice of non-coverage letter. There are various letters required. Review the requirements at All Medicare residents coming off Medicare A coverage need to receive the Quality Improvement Organization (QIO) notice and those who are staying in the facility at a different level of service also need to receive the Advanced Beneficiary Notice (ABN) with their appeal rights.