Caryn Adams

I was denied payment for a Medicare resident who did not have a 60-day break in stay. Wasn’t this covered in the blanket waiver? 

Yes, and no.  While the waiver says “for certain beneficiaries who exhausted their [skilled nursing facility] benefits,” it authorizes renewed SNF coverage without first having to start and complete a 60-day “wellness period” (that is, the 60-day period of noninpatient status that is normally required to end the current benefit period and renew SNF benefits). What many facilities did not remember is that this waiver will apply “only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the 60-day ‘wellness period’ that would have occurred under normal circumstances.”

First, be sure that the claim includes the “DR” code to ensure the Medicare Administrative Contractor can identify that this should be covered by the waiver. I have heard that the denials are because of “no COVID diagnosis.” Review the reason that the wellness period was delayed or prevented. If it can be linked to the pandemic, appeal with documentation to support the reason you feel that it is related to the pandemic. Remember also that if the patient has a continued skilled care need (such as a feeding tube) that is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits under the Section 1812(f) waiver, as it is this continued skilled care in the SNF rather than the emergency that is preventing the beneficiary from beginning the 60-day “wellness period.” 

I anticipate more denials as the country reopens and CMS looks to recoup funding. This also includes payments for facilities that have used the three-day hospital stay waiver. I encourage facilities to appeal with appropriate supporting documentation.