There are some specific rules that pertain to the Skilled Nursing Facility (SNF) services and Medicare coverage. Skilled services are specific skills that are provided by health care employees like physical therapists, nursing staff, pathologists, and physical therapists.
Rules include doctor ordered care with certified health care employees. Also, they must treat current conditions or any new condition that occurs during the SNF’s care.
Skilled Nursing Facility Requirements for Medicare Coverage
There are specific qualifications that beneficiaries must meet to qualify for Medicare coverage for skilled nursing facilities.
The patient must have been an inpatient of a hospital facility for at a minimum of three consecutive days. The patient must go to an SNF that has Medicare certification within thirty days of their hospital discharge.
There are exceptions to this rule.
If the patient’s health conditions are not appropriate for placing into a nursing facility directly after leaving the hospital, the hospital will determine when to begin appropriate care. Another exception to this rule is if the patient requires around the clock nursing services.
Part A Benefits
Medicare Part A benefits cover 20 days of care in a skilled nursing facility. After that point, Part A will cover an additional 80 days with the beneficiary’s assistance in paying their coinsurance for every day.
Once the 100-day mark hits, a beneficiary’s SNF benefits are “exhausted”. At this point, the beneficiary will have to assume all costs of care, except for some Medicare Part B health services.
The Benefit Period
Benefit periods are how SNF coverage is measured. These periods begin on the day that the beneficiary is in the healthcare facility on an inpatient basis. This period ends when the beneficiary is no longer an inpatient and hasn’t been one for 60 consecutive days.
A new benefit period may begin once the prior benefit period ends, and the beneficiary receives another admission to a healthcare facility. One keynote to remember is that a new benefit period is not each calendar year or change to the patient’s diagnosis or health condition.
Communicating with Beneficiaries and Providers
There is plenty for providers to communicate with their patients about when it comes to SNF’s. They’ll discuss if this is a good fit, the coverage requirements, and determine if staying at an SNF is medically necessary.
Skilled Nursing Facilities and Payments
Medicare Part A covers all inpatient services at SNF’s.
Consolidated Billing – SNF’s bill out healthcare services under Medicare Part A, as well as other sources, into one bill.
Medicare Part B covers outpatient health services for beneficiaries who aren’t SNF inpatients. Coverage for health services is possible after exhausting Part A benefits.
Medicare Coverage Requirements for Skilled Nursing Facilities
SNF’s can bill Medicare Part A by making sure to send in claims in order. Claims go out after a beneficiary leaves from the facility or after the benefit period.
Unique Billing Situations
There are instances where Medicare may require a claim, even when payment isn’t a requirement.
Readmission Within 30 Days
When the beneficiary is discharged from a skilled nursing facility, and then readmitted within 30 days, this is considered readmission. Another instance of readmission is if a beneficiary were to be in the care of an SNF and then end up needing new care within 30 days post the first noncoverage day.
If a patient exhausts benefits, the monthly bills continue with normal submission; although, the beneficiary must still be in a Medicare facility.
Full exhausted benefits mean that the beneficiary doesn’t have any available days on their claim. Partially exhausted benefits mean that the beneficiary had several available benefit days on their claims.
No Payment Billing
No payment billing happens when a patient moves to a non-SNF care level and is in a Medicare facility.
Expediting Review Results for Beneficiaries
Expediting the determination processes can happen when providers initiate discharge from SNF’s because of coverage reasons. Although, beneficiaries can appeal health service terminations through this process.
SNF requirements must be met to obtain benefits.
Billing Situations Among Other Facilities
If a beneficiary needs an SNF and goes but doesn’t have a qualifying stay in a hospital facility, they can move to an SNF after they remain for the night. They’ll then go the next night and receive coverage.
3-Day Rule Medicare Billing for Coverage in Skilled Nursing Facilities
For a beneficiary to extend healthcare services through SNF’s, the patients must undergo the 3-day rule before admission.
The 3-day rule ensures that the beneficiary has a medically necessary stay of 3 consecutive days as an inpatient in a hospital facility.
This doesn’t include the day of the patient’s discharge, any outpatient observations, or time spent in the emergency room.
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