Case Management During COVID-19: Accessing Medicare & Managed Care Benefits for Treating SNF Patients

Thoughtware Alert Published: Apr 09, 2020
Stethoscope and laptop

The SARS-CoV-2 virus and incidence of COVID-19 are challenging all providers in the healthcare continuum to re-evaluate the populations they serve and scope of services they’re offering. Some nursing homes are transferring their residents to other nursing homes and setting up COVID-19 facilities. Children’s hospitals are sending children home if they can be cared for safely and gearing up to handle the overflow of non-COVID-19 patients from local health systems. Temporary hospitals are being set up in convention centers and city parks. 

Skilled nursing facilities (SNF) have been attempting to “treat in place” and reduce transfers to the hospital whenever possible. During this crisis, this approach to care delivery is even more important to help limit exposure for your residents. However, treating in place can be expensive and potentially adds to the financial burden of this pandemic. 

Medicare Part A 

CMS’ 1135 waiver eliminated the requirement for a three-day hospital qualifying stay, which can provide access to the patient’s Medicare Part A benefits while providing the necessary higher level of care. It’s important that clinical documentation adequately supports the use of the Medicare benefit. Documentation should include:

  • Physician documentation of the diagnosis requiring the skilled services and that the patient would be hospitalized except for the lack of hospital beds and/or the risk for exposure to COVID-19.
  • Documentation of the specific skilled services that support the Medicare Part A stay. In most cases, the resident will be qualified under skilled nursing services such as IV medications, IV fluids, respiratory treatments and assessments.
  • Rehabilitation services may be the qualifying skilled service; however, the documentation should be very specific on justifying how the patient would have typically been admitted to the hospital. Verify that all Medicare Part A skilled criteria are met before initiating the Medicare coverage for therapy services only. The criteria include daily therapy services at least five days a week, decline in function due to the new diagnosis or other event and services could only be provided on an inpatient basis. This waiver shouldn’t be used for residents who may be identified as part of the routine MDS process as needing Part B therapy services.

Managed Care 

Managed care organizations (MCO) already can adjust the level of care for their members without a hospitalization. Many MCOs contract with providers for levels of care and have specific clinical criteria that define the various levels. The challenge is often obtaining authorization for the higher level of care for a resident who’s currently in the facility. Documentation by the physician and clinical staff is key to justify the change to a higher level of payment by the plan’s case manager.  

Strategies to Successfully Manage Medicare & Managed Care Benefits During the COVID-19 Crisis

Many SNFs don’t have case management staff dedicated to monitoring residents to identify changes in their level of care and developing systems to access the appropriate level of reimbursement. Typically, the MDS coordinator or possibly the social service staff are responsible for coordinating with the MCOs. It’s important the designated staff can focus on identifying changes in condition to determine that the criteria for a change in payor source and/or payment are validated. 

Some operational strategies to consider:

  • Provide education for admission, MDS/case management and therapy managers on the three-day hospital waiver and the criteria to use to implement the waiver. 
  • Educate your physicians on the services you can provide in your facility and the documentation they’ll need to complete to support the higher level of care and reimbursement. Review the requirement for certification for skilled services necessary for Medicare billing.
  • Provide MDS/case management staff with the clinical criteria for the levels of care that are specified in MCO contracts. Develop a grid that’s easy to understand and use to evaluate the resident’s level of care daily.
  • Evaluate your MDS coordinator’s access to the resident’s insurance information. If the information is restricted, then designate who in the organization is responsible to verify coverage.  
  • Establish a process for notifying the MDS coordinator/case manager whenever there’s a change in condition that may affect reimbursement. With reduced in-person meetings, the process may need to switch to a daily telephone clinical review with unit managers or rounds by the MDS coordinator/case management staff.
  • Develop a process for the MDS/case manager to document in the resident’s record the rationale for initiating Medicare Part A coverage or requesting a higher level of care for managed care. This will be helpful in any future audits.

As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication.

If you have any questions, please reach out to your BKD Trusted Advisor or submit the Contact Us form below. 

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