Acentra Health BFCC-QIO

Webinar Questions and Answers
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unlocking insights: exploring medicare skilled nursing facility trends and lessons learned

The following are questions and answers from the webinar provided by Acentra Health on August 28, 2024.

appeal concerns

Let's say we have an insurance company that issues a last covered day (LCD) for a Thursday. The beneficiary and family appeal the decision on Wednesday. The physician disagrees with the notice and says to continue with the current stay. We are notified of this on Thursday. The insurance company wants an update on Monday and then reissues the LCD. How can we prevent this from happening? I sometimes see two LCDs in the same week from the insurance company, and when you get them, you overturn this decision. This is very stressful for the beneficiary. Then they don't do as well in therapy, as they are worried about these outcomes.

The burden of proof resides on the provider and health plan to ensure that the decision to discontinue the last skilled service is appropriate. The provider’s documentation needs to support that decision. If submitted documentation does not support that decision, Acentra Health will likely agree with the beneficiary and disagree with the intent of the notice.
Do you ever request additional documentation from a skilled nursing facility (SNF) to get a clearer picture? I often see in the overturn that the information was not provided.

Yes, If the time frame allows, courtesy calls are made for necessary missing medical record information that would give the physician reviewer the information needed to make a determination. We ask that records be uploaded within one hour to ensure a timely review.
Why are Notices of Medicare Non-Coverage (NOMNC) being noted by Acentra Health as invalid because the form failed to include the signature of the receiver or medical records did not contain documentation that the beneficiary was verbally notified? Forms are seldom signed upon notification, as the informed is not at the facility. However, verbal notice is documented on the NOMNC and in the chart. Acentra Health fails to look at the medical records submitted to see that we also sent nursing documentation.

From Chapter 30 of the Claims Processing Manual, 260.3.8 – NOMNC Delivery to Representatives:

If the NOMNC must be delivered to a representative not living with the beneficiary, the provider is not required to make an off-site in-person notice delivery to the representative. The provider must complete the NOMNC as required and then telephone the representative at least two days before the end of covered services. The provider should inform the representative of the beneficiary’s right to appeal a coverage termination decision.

The information given to the representative should include the following:
- The beneficiary’s last day of covered services, and the date when the beneficiary’s liability is expected to begin
- The beneficiary’s right to appeal a coverage termination decision
- A description of how to request an appeal by a quality improvement organization (QIO)
- The deadline to request a review as well as what to do if the deadline is missed
- The telephone number of the QIO to request the appeal
The date the provider communicates this information to the representative, whether by telephone or in writing, is considered the receipt date of the NOMNC. The NOMNC must be annotated on the day that the provider makes telephone contact to reflect that all the required information was communicated to the representative.

A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiary’s medical file.

Note the following:
- The name of the staff person initiating the contact
- The name of the representative contacted by phone
- The date and time of the telephone contact
- The telephone number called

Could you please elaborate on the second appeal process?

If the QIO agrees with the NOMNC, the beneficiary has the right to a reconsideration appeal. Acentra Health reviews reconsideration appeals for Medicare Advantage (MA) plan enrollees. For beneficiaries with Original Medicare, another Centers for Medicare & Medicaid Services (CMS) contractor, called the Qualified Independent Contractor (QIC), reviews the reconsideration appeal.

The QIO must issue its reconsidered determination within 14 calendar days of receipt of the enrollee's request for a reconsideration.

If the initial determination is upheld, the beneficiary is financially liable from the original liability date.

If the initial determination is overturned on reconsideration, the beneficiary can continue skilled services until another NOMNC is issued.

The beneficiary may appeal the reconsidered determination to the Office of Medicare Hearing and Appeals (OMHA) for an Administrative Law Judge (ALJ) hearing if the beneficiary/family has paid, out of pocket, at least $200.00.
We are experiencing multiple beneficiaries winning more than five appeals. How can the MA contractors be following Medicare guidelines according to Section 8 if Acentra Health overturns the NOMNC? This is extremely time-consuming for the providers issuing multiple NOMNCs.
Each MA plan has a CMS representative in the respective regional office. These representatives can assist with situations where providers have questions about the plan’s performance. This question would be best answered by the CMS representative. If you do not know who the CMS representative is in your region, please reach out to Rose Hartnett (rosemarie.hartnett@acentra.com) or Cheryl Cook (cheryl.cook@acentra.com) for assistance.
We recently had a family try to cancel an appeal. The family stated that the person they talked to from Acentra Health said they would take care of it. We ended up receiving a determination anyway, and it was never canceled. What steps should a family take if they want to cancel an appeal once it's started?

Due to the specific circumstances of this question, the Appeal ID is needed to research the events. Please provide the appeal identification number to Rose Hartnett (rosemarie.hartnett@acentra.com) or Cheryl Cook (cheryl.cook@acentra.com) so that Acentra Health can research the events surrounding this appeal.
I see lots of determination letters that contradict the documentation packet that was sent in. I assume this is due to reviewers missing key data points within the stacks and stacks of paperwork that they are sent. Do you have a standardized form that has all the critical information to determine a skilled need?

We do not use a standardized form. Our physician reviewers read the information in the medical record provided. It is helpful to include key information in the most recent treatment encounter notes and nursing notes. You should not receive a letter with information that contradicts the documentation packet that was sent in; if that occurs, please email AppealsCoordinators@acentra.com.
We recently had an admission. The therapist evaluated and determined that the beneficiary did not require Medicare Part A services. Therefore, we provided a NOMNC. The family appealed, and Acentra Health sided with the family because we did not provide a two-day notice. We were unable to provide a two-day notice, as we were not providing therapy. When I questioned Acentra Health, I was told we shouldn't have given the notice because there was nothing to appeal. The rules we can find state that we do need to give notice, as the beneficiary still has the right to appeal because they had a three-day qualifying stay before admission to our facility. Can you clarify?

Due to the specific circumstances of this question, the Appeal ID is needed to research the events. Please provide the appeal identification number to Rose Hartnett (rosemarie.hartnett@acentra.com) or Cheryl Cook (cheryl.cook@acentra.com) so that Acentra Health can research the events surrounding this appeal.
Do you work with appeal issues with MA plans? It seems in our area that the MA plan states that the beneficiary can go home, even though the facility and the physical therapist believe the beneficiary still needs 24/7 care. Do they have to appeal through the plan and not through Acentra Health?

No, the BFCC-QIO handles beneficiaries’ appeals of skilled service terminations and hospital discharges. If the enrollee receives a NOMNC, their appeal rights are through the BFCC-QIO unless they have already started an appeal through the plan. The NOMNC should clearly state how the enrollee can activate his/her appeal rights through the BFCC-QIO.
Can you comment on when you disagree with a notice being issued and then the insurance company asks for an update later and reissues the NOMNC?

Whenever the BFCC-QIO disagrees with the intent of the NOMNC, the provider and/or health plan can reissue the NOMNC. Once the second, third, or fourth NOMNC has been issued, the Medicare beneficiary can activate their appeal rights through the BFCC-QIO.
Can you talk about the appeals process? Is there an opportunity for the SNF team to connect directly with Acentra Health if the appeal is upheld? How can a Medical Director of a delegated MA plan, discuss an appeal or a disagree determination with the clinical staff at Acentra Health?

Providers can contact our Operations Director, Rose Hartnett, at rosemarie.hartnett@acentra.com or our Program Director, Cheryl Cook, at cheryl.cook@acentra.com with questions related to determinations. Please include specific case IDs and questions in your email.
I have a beneficiary who missed the appeal window, so the SNF is saying that the beneficiary can appeal to the health plan. I am a utilization nurse at a plan, and we have never had a beneficiary appeal directly to us before. Is this something we are required to do, or can we just say all appeals must go through Acentra Health?

Currently, if a beneficiary requests an appeal after the deadline (after 12:00 p.m. the day before the effective date), the MA organization completes the review. Under current regulations, MA enrollees do not have the same access to a BFCC-QIO review of a fast-track appeal as Traditional Medicare beneficiaries. Effective January 2025, the BFCC-QIO, instead of the MA plan, will review untimely MA appeals. This will bring MA regulations in line with the parallel reviews available to beneficiaries in Traditional Medicare and will expand the rights of MA beneficiaries to access the fast-track appeals process in connection with skilled service terminations.
In terms of the documentation not being older than seven days, facilities are asked to present therapy evaluations that are most likely older than seven days. Are you looking for new assessments and goals within those seven days?

Some medical record documentation will be older than seven days, such as the initial therapy evaluations and progress reports. However, we should also see recent information about the beneficiary’s current level of function and current clinical condition. These are typically found in treatment encounters and nursing notes and should not be older than seven days before the last covered day.
If the SNF thinks the beneficiary still needs skilled care but the MA plan denies continued coverage/payment, who has the burden to prove that termination of coverage is correct? It seems the MA plan does.

The burden of proof resides on the provider and health plan to ensure that the decision to discontinue the last skilled service is appropriate. The provider’s documentation needs to support that decision. If the submitted documentation does not support that decision, Acentra Health will likely agree with the beneficiary and disagree with the intent of the notice.
Per the quote from Chapter 8, section 30.2.2.1, if a beneficiary’s goals are reduced due to a lack of progress, will the reviewer continue to use the prior level of function as a justification for skilled service?

Physician reviewers assess multiple data points beyond a beneficiary’s prior level of function, to consider their full clinical picture. The goals established by therapy services play a critical role. If those goals were adjusted during treatment, the reviewers consider these new goals. The primary question is whether ongoing daily skilled care in a SNF is medically reasonable and necessary. Reviewers assess if daily therapy services in a SNF are still medically necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.
You noted that MA plans represent 90 percent of appeals. At what percentage of MA appeals do your reviewers agree with the non-coverage decision compared to appeals by regular Medicare?

Our internal data shows that in 58 percent of appeals, we agree with the intent of the NOMNC for MA enrollees compared to the 63 percent agreement rate with traditional Medicare beneficiaries.
Upon issuing the NOMNC, the beneficiary appeals the decision. The beneficiary loses but then appeals again. Does the facility continue to provide Medicare services during the appeal decision? How many times can a beneficiary appeal the decision?

The Medicare beneficiaries/enrollees have five levels of appeal. These levels are initial, reconsideration, Administrative Law Judge, Medicare Appeals Council, and federal court. The beneficiary only has financial protection if they request a timely appeal when they are given the NOMNC. Should the BFCC-QIO agree with the provider/plan that the beneficiary is ready for a lower level of care, if skilled care continues after the Effective Date, the beneficiary is financially liable for all charges. The beneficiary can ask for a reconsideration review; however, the time frame to complete the review is up to 14 calendar days, and there is no financial protection.
Does Acentra Health require that the records come from the SNF, or do you consider and process the appeal based on the copy of medical records that is sent by the MA plan?

Medical record requests are sent to both the healthcare provider and health plan. We process the appeal based on the beneficiary’s medical records regardless of which entity submits them. Ideally, the healthcare provider and health plan representatives work together to ensure the medical records are timely submitted.
Your data on diagnoses only represent those who appealed their discharge, not all SNF beneficiaries in a covered stay. Do you have data on all beneficiaries in SNFs to determine if the diagnoses you noted are more likely to appeal or are simply a higher proportion of beneficiaries in SNFs?

The data presented did represent those beneficiaries who activated their appeal rights. Your suggestion regarding data for all SNF beneficiaries is a good one, and our team can query CMS data systems to determine if our findings correlate to all SNF admissions.
I have routinely had discharges from the SNF overturned even though the appeal determination from Acentra Health states that skilled services are not needed or required daily. Why is that?

Due to the specific circumstances of this question, Appeal IDs are needed to research the events. Please provide the appeal identification number to Rose Hartnett (rosemarie.hartnett@acentra.com) or Cheryl Cook (cheryl.cook@acentra.com) so that Acentra Health can research the events surrounding this appeal.

The following provides guidance to address Questions 21 – 24.
I have noted some trends in the decisions made on appeals that go against what I have known as Medicare guidelines for the last decades and wonder if there is someone I could speak to for more information. For example, when beneficiaries have a weight-bearing restriction, I have always been told that they should stay on a skilled level until they have reached their maximum functional level and then should come off skilled benefit until their weight-bearing status is increased and further progress can be made at which time they should go back on skill. But this is not what we have seen when appeals are made. We also see beneficiaries who are not making gains and seem to be at a new baseline. They are staying for long-term care and winning appeals, which confuses us. I work with several facilities, and there have been cases where therapists are saying they feel guilty continuing to bill Medicare when beneficiaries are not progressing and do not require skilled therapy, yet they are winning appeals.
How does this apply to someone who is non-weight-bearing for eight weeks due to a broken hip? Does this mean they should stay skilled until they can participate in weight-bearing activities?
Related to the weight-bearing question, if a beneficiary can't do any more until orthopedics upgrades their weight-bearing status in four weeks, are those four weeks covered? Families have a difficult time believing that if the beneficiary is doing the most they can and still needs assistance but isn't going to progress until weight-bearing increases, Medicare won't cover.
Are you saying it's appropriate to issue the NOMNC when beneficiaries are still non-weight-bearing?

Per the Medicare Benefit Policy Manual Chapter 8, Section 30, care in a SNF is covered if all the following four factors are met:
- The patient requires skilled nursing or rehabilitation services.
- The patient requires these skilled services daily (therapy five days/week, nursing seven days/week).
- As a practical matter, the daily skilled services can only be provided on an inpatient basis.
- The services are reasonable and necessary for the treatment of the patient’s illness or injury.
For a non-weight-bearing beneficiary, the assessment would focus on whether continued daily skilled services in a SNF setting are reasonable and necessary. Goals should be designed to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. For example, goals may need to focus on bed mobility, safe transfer from bed to chair/toilet, and learning to maneuver a wheelchair. However, once the point is reached where daily skilled services in an SNF are no longer reasonable and necessary, it would be appropriate to issue a NOMNC. The decision should be based on the patient's medical needs and accepted medical practice standards.

We recognize that there are instances where a patient’s clinical condition results in a current level of function that is significantly worse than their prior level with no expectation for improvement within a reasonable time frame. In such cases, it is vital that we see documentation of an established maintenance program and/or teaching and training of beneficiaries and their caregivers. This ensures that beneficiaries and/or their caregivers are equipped with the necessary skills and knowledge to help maintain the beneficiary's current condition and prevent or slow any decline or deterioration. It also helps to assess if skilled services are necessary for the safe and effective performance of a maintenance program. We are better able to address this concern if you send us specific cases where you feel that continued daily skilled therapy is not reasonable. Please email the case ID to AppealsCoordinators@acentra.com.

The following provides guidance to address Questions 25 – 34.

snf concerns

How would you handle a scenario where the beneficiary has met their new expected goals, which may be different than the prior level of function, but there is no willing caregiver? All the beneficiary requires is custodial care.
How do you handle beneficiaries who do not have family members to help train or decline a higher level of care to continue the intermittent therapy/nursing needs?
The impaired mobility that you discussed in question #2 requires the family to be taught and maintenance programs to be created. Sometimes we cannot get family on board, or they refuse. How do we handle this?
What about beneficiaries who have undergone an amputation and wish to remain in the SNF until they are fitted and able to use their prosthetic instead of gaining independence with wheelchair mobility?
For the beneficiary who may never walk over 50 feet without minimal assistance after SNF services, and a maintenance plan is in place but will need to be carried forward in long-term care, do you advise the provider to exhaust the SNF benefit before long-term care placement?
When a plateau in functional improvement has been reached despite daily therapy, and the services have shifted to maintenance, does this continue to require a daily skilled service in the inpatient setting? Would daily skilled therapy then exceed the need?
What if home modifications are recommended and discussed with the family and 60 days have passed because they drag their feet? For example, adding a rail to the stairs or ramp.
At what point do you begin to consider the therapy treatment being delivered when limited progress is noted, such as repetitive therapeutic exercises or the use of a UE or LE ergometer without documentation of functional training?
If a lack of progress is not justification for skilled services, is the opposite also true (a beneficiary who is strong enough to return home but is making progress)? Can you define what skilled services are?
You spoke about functional mobility but not occupational therapy, things like toileting, meal preparation, etc. We have beneficiaries who live alone, have no support services, and cannot toilet themselves. They are cut off while they are still improving. What can be done for them?

30 - Skilled Nursing Facility Level of Care - General

Per the Medicare Benefit Policy Manual Chapter 8, Section 30, care in a SNF is covered if all the following four factors are met:
- The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel.
- The patient requires these skilled services daily (therapy five days/week, nursing seven days/week).
- As a practical matter, the daily skilled services can only be provided on an inpatient basis.
- The services are reasonable and necessary for the treatment of the patient’s illness or injury.
30.2.1 - Skilled Services Defined

Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. In these cases, the complications and special services involved must be documented by physicians' orders and notes as well as nursing or therapy notes.

30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services

30.3 - Direct Skilled Nursing Services to Patients
- A service is not considered a skilled nursing service merely because it is performed by or under the direct supervision of a nurse. If a service can be safely and effectively performed (or self-administered) by an unskilled person, the service cannot be regarded as a skilled nursing service although a nurse provides the service. Similarly, the unavailability of a competent person to provide a nonskilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a nurse provides the service.
30.4.1 – Skilled Physical Therapy
- Some SNF inpatients do not require skilled physical therapy services but do require services, which are routine in nature. When services can be safely and effectively performed by supportive personnel, such as aides or nursing personnel, without the supervision of a physical therapist, they do not constitute skilled physical therapy. Additionally, services involving activities for the general good and welfare of the patient (e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation) do not constitute skilled physical therapy.
30.4.1.2 - Application of Guidelines Section E. Maintenance Therapy
- Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (See 42CFR §409.32) If all other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services do not constitute a covered level of care.

How do we manage chronic daily wound care when it can safely be done at a lower level but is done daily in the SNF, and there is no treatment change for more than 30 days?

The following excerpts from the Medicare Beneficiary Policy Manual Chapter 8 provide guidance to address this question. Please review the entire section for more complete information.

30.3 - Direct Skilled Nursing Services to Patients
- Nursing services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse.
- If all other requirements for coverage under the SNF benefit are met, skilled nursing services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a registered nurse or, when provided by regulation, a licensed practical (vocational) nurse are necessary.
- Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided, and all other requirements for coverage under the SNF benefit are met. Coverage does not turn on the presence or absence of an individual’s potential for improvement from nursing care, but rather on the beneficiary’s need for skilled care
- A service is not considered a skilled nursing service merely because it is performed by or under the direct supervision of a nurse. If a service can be safely and effectively performed (or self-administered) by an unskilled person, the service cannot be regarded as a skilled nursing service although a nurse provides the service. Similarly, the unavailability of a competent person to provide a nonskilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a nurse provides the service.

How do you appropriately assess the ability of beneficiaries that have a behavioral health/psychiatric component to their inability to ambulate or rehabilitation?

If a beneficiary has a behavioral health/psychiatric component to their inability to ambulate, the beneficiary should be assessed to determine if they require daily skilled nursing services or admission to an acute care setting for their condition. If they do not require daily skilled nursing services or admission to an acute care setting and are unable to participate in daily therapy more than an isolated break of a day or two, follow the guidance provided below.

The following excerpts from the Medicare Beneficiary Policy Manual Chapter 8 provide guidance to address this question. Please review the entire section for more complete information.

30.2.2.1 - Documentation to Support Skilled Care Determinations
- If it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.
30.6 - Daily Skilled Services Defined
- Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a “daily basis,” i.e., on essentially a seven-days-a-week basis.
- A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the “daily basis” requirement when they need and receive those services on at least five days a week. (If therapy services are provided less than five days a week, the “daily” requirement would not be met.)
- This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.
Are activities of daily living performance considered?

The following excerpts from the Medicare Beneficiary Policy Manual Chapter 8 provide guidance to address this question. Please review the entire section for more complete information.

30.5 - Nonskilled Supportive or Personal Care Services

The following services are not skilled services unless rendered under circumstances detailed in §§30.2:
- Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;
- Routine care of the incontinent patient, including the use of diapers and protective sheets;
- Assistance in dressing, eating, and going to the toilet;
- Periodic turning and positioning in bed; and
- General supervision of exercises, which have been taught to the patient and the performance of repetitious exercises that do not require skilled rehabilitation personnel for their performance. (This includes the actual carrying out of maintenance programs where the performances of repetitive exercises that may be required to maintain function do not necessitate a need for the involvement and services of skilled rehabilitation personnel. It also includes the carrying out of repetitive exercises to improve gait and maintain strength or endurance; passive exercises to maintain range of motion in paralyzed extremities which are not related to a specific loss of function; and assistive walking.)
A beneficiary has taken a turn, and the family has chosen care and comfort. The nurses are assessing pain, managing secretions, and respirations, and the physician is making medication changes. Nurses are also managing behaviors associated with terminal agitation. Does this meet the skilled criteria?

It is most appropriate to refer these beneficiaries to hospice. Hospice care is a benefit under the hospital insurance program. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.

While awaiting hospice care, daily skilled nursing is appropriate if:
- Skilled involvement is required for the services in question to be furnished safely and effectively; and
- The services themselves are, in fact, reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice.
The following excerpt from the Medicare Beneficiary Policy Manual Chapter 8 provides guidance to address this question. Please review the entire section for more complete information.

30.2.3 - Specific Examples of Some Skilled Nursing or Skilled Rehabilitation Services
- 30.2.3.1 Management and Evaluation of a Patient Care Plan: The development, management, and evaluation of a patient care plan, based on the physician’s orders and supporting documentation, constitute skilled nursing services when, in terms of the patient’s physical or mental condition, these services require the involvement of skilled nursing personnel to meet the patient’s medical needs, promote recovery, and ensure medical safety.
- 30.2.3.2 - Observation and Assessment of Patient’s Condition: Observation and assessment are skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures, until the patient’s condition is essentially stabilized.

What if a SNF is not documenting the beneficiary’s status and discharge plan, which is being reviewed verbally in family meetings?

One of the most critical aspects of our appeals process is medical record documentation. This documentation is not merely a formality; it is the linchpin for determining whether continued daily skilled services in a SNF setting are reasonable and necessary. As outlined in Title 42 of the Code of Federal Regulations in section 405.1202 section D, when a beneficiary requests an expedited determination by a QIO, the burden of proof falls squarely on the provider. It is the provider's responsibility to demonstrate that the termination of coverage is the correct decision, whether based on medical necessity or other Medicare coverage policies. This burden of proof can only be met through thorough and accurate documentation in the medical record. It is vital that this documentation is up to date. Information regarding the beneficiary’s current condition or level of function should not be older than seven days before the date services will end. This ensures that the most current and relevant information is available to support accurate and fair appeals determinations.
If a facility does not establish a maintenance plan and teach and train the beneficiary and/or their family, the continued stay will be approved. This benefits the facility. How can Acentra Health address these misaligned incentives?

While we can't address "misaligned incentives" as mentioned in this question, we are charged with ensuring that all Medicare beneficiaries received professionally recognized standards of care. However, if it is suspected that a beneficiary is not given appropriate care or there is a pattern of inappropriate care, then a quality of care concern referral could be made. Specific beneficiary names and dates of service would be needed.

Chapter 5 of the Quality Improvement Organization manual defines quality of care as the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. A quality of care concern arises when the care provided does not meet professionally recognized standards of health care. Medicare Administrative Contractors (MACs), Medicare health plans (MHPs), State Medicaid survey and certification agencies (SSA), other CMS contractors, CMS staff, and anonymous sources may refer cases involving potential quality of care concerns to the BFCC-QIO.
Isn’t the determination of whether services are reasonable and necessary somewhat of a judgment call?

The following excerpt from the Medicare Beneficiary Policy Manual Chapter 8 provides guidance to address this question. Please review the entire section for more complete information.

30 - Skilled Nursing Facility Level of Care – General
- The services delivered must be reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.
How many of these beneficiaries go home from SNF with home health versus no additional care?

For this data presentation, the final disposition of the beneficiaries or members was not reviewed.

other

Is the QIO Communications email address also for technical denial questions?

The QIO Communication email address can be used to submit questions associated with a “technical denial.” That said, we cannot ensure the protection of any protected health information (PHI)/personal identifiable information (PII) sent via email. We would encourage the use of identifiers noted on the Technical Denial letters when emailing your questions.
What does Acentra Health need to see when a physician has recommended hospice services?

If this is in reference to a hospitalized beneficiary and that beneficiary has elected hospice services, he/she does not receive the follow-up Important Message from Medicare notice. This is an elected benefit, and the beneficiary is not eligible for a hospital discharge appeal.
I've been getting a lot of denials from an MA plan based on their statement that section GG isn't timely signed. Our company has an evaluation that clearly shows the collection date is within the first three days. The MA plan refuses to accept this as proof that the information was timely collected, and they changed the HIPPS code by taking out the section GG coding on the MDS. Is this something you can answer for me?

This is a question that is outside of the BFCC-QIO’s scope.
Are these findings shared with the MA plans as well?

Medicare health plans were invited to attend this data presentation. We have shared this information with individual health plans during our collaboration calls with them.
For the diagnosis trend, is this the primary diagnosis on the claim?

The diagnosis is obtained from the medical record review.
Please list the references and guidelines for the slide titled "Guidelines for skilled nursing facility care."

Medicare Benefit Policy Manual Chapter 8, Section 30

30 - Skilled Nursing Facility Level of Care - General

In accordance with the Medicare Benefit Policy Manual Chapter 8, Section 30, care in a SNF is covered if all the following four factors are met:
- The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel
- The patient requires these skilled services daily (therapy five days/week, nursing seven days/week).
- As a practical matter, the daily skilled services can only be provided on an inpatient basis.
- The services are reasonable and necessary for the treatment of the patient’s illness or injury.
What is the age grouping for each plan? Is one more elderly than the other?

We do not have age trends at this time.