I received a denial for a resident who was at another facility, transferred to the hospital and subsequently admitted to our facility. Shouldn’t this have been covered by one of the current waivers?

The waivers are still in place, but there are many variables that may contribute to the denial of payment.  

It’s possible that the resident exhausted his or her 100-day benefit and stayed skilled in the other facility prior to the hospital transfer. This resident would not qualify for another 100 days and definitely could put the receiving facility at a disadvantage.  

Therefore, it is important for evaluators at the new facility to do due diligence to determine exactly how many days were used, how many are left, and if the 100 days were exhausted, whether or not the resident remained skilled. 

In addition to denials, Recovery Audit Contractors are authorized to conduct medical review. They are reviewing for Medical Necessity and Documentation Requirements in general, but as of September 2020, specifically related to Patient Drive Payment Model characteristics.  

Even with waivers in place, the Medicare requirements have not changed.  If the resident does not require skilled care, then the requirement is not met. It can be as simple as that.

Also, remember that non-hospital transfers do not have the presumption of coverage. While the waivers are intended to make it easier to care for our residents, there are a lot of areas which can open up the facility to financial risk. It is imperative that providers move with care and precision, in order to avert potential costly litigation or corrective actions.

As always, I would encourage the facility to appeal any denial and review any other residents in this situation to avoid potential concerns.