SNF Caution: Medicare and End of Life Billing
While this isn’t a de novo trend, it is one that I am seeing again with frequency and thus, it bears/requires CAUTION. This trend is commonly referred to as Skilled until Death or End-of-Life Skilled. The reference in “skilled” is Medicare; delivering qualified skilled nursing or skilled therapy services (or combination thereof) with sufficient frequency and intensity to qualify the resident for Medicare coverage, post a three-day qualifying hospital inpatient stay. The genesis of this trend lies in the differences between the Medicare benefits found in the SNF/traditional Part A program and the Medicare Hospice benefit. The logic for families/residents is as follows (why or why not hospice, etc.).
A patient in a hospital, likely terminal in a short time period and incapable (for a myriad of reasons) of returning home, is approaching discharge. The inpatient stay length in the hospital is sufficient to meet the three-day rule for Medicare A coverage in the nursing home. The patient’s condition likewise is such, that he/she will meet the eligibility test for coverage under the Medicare Hospice benefit. Here’s the nuance. If the patient elects the Medicare Hospice benefit and requires an inpatient stay in an institutional setting, such as an SNF, prior to his/her death, the patient must pay the prevailing cost of the room and board component. The caveat is unless the patient is eligible or qualified for Medicaid and then, the Medicaid program would pay the SNF for the room and board cost. The Hospice benefit does not cover such a cost unless the inpatient stay was respite or qualified as General Inpatient for advanced symptom management, etc. Under the Medicare Part A SNF benefit, the patient may discharge to the SNF, receive the first 20 days of covered care essentially free and then, if still qualified, pay a lower cost per diem co-pay for any covered days past the initial 20. In this simplistic fashion, it seems logical for most parties that unless the patient was Medicaid eligible, the best route is to remain on traditional Medicare and access the Part A SNF benefit. For families and patients, this makes sense but for providers; SLOW DOWN! Showing my age and “borrowing” from a TV favorite in my past, “Danger Will Robinson … Danger”.
The Medicare Part A SNF benefit does not contain any RUG related to End of Life or Palliative Care. In fact, there is no presumption of payment for any end of life care under the Part A SNF benefit as the same was never meant to be used for any reason other than a post-acute transfer style payment up and until, the patient could re-transition to his/her permanent residence, off of the Medicare coverage. Thus, the only aspects of coverage determination/eligibility (sans the 3 day prior rule) is the medical necessity of daily skilled services defined as professional nursing (RN), rehabilitative therapies (PT, OT, ST) or some combination between nursing and other related skilled disciplines such as respiratory therapy, dietitians, etc. Many of the traditional end-of-life hospice/palliative type services would not, meet any of the Medicare Part A SNF “skilled” coverage criteria. Simple management of pain or symptoms without necessitating routine RN assessment and dosage changes isn’t a skilled SNF service. IV’s in and of themselves, don’t engender lots of skilled nursing coverage. If someone is likely to die in a reasonably short time, therapies are unwarranted for any length of time, save perhaps a day or two to develop other care plans for swallowing, positioning, etc.
How this subject rises to the CAUTION level is driven by two separate but inter-operative elements in government today. First, the heightened focus from the OIG on SNF care, its appropriateness, its billing issues, etc. The industry is watched closer today than ever and RAC and Other audits are heating up. Second, the government’s vigilance and determination today in finding fraud, particularly acts/violations of the False Claim Act. Now, lest anyone thinks I am being too alarmist, I have a long list of clients within my consulting practice work that are using us to help with post-payment reviews and claims denials for SNF Part A claims.
The take-away here is very simple….if it walks like a duck, quacks and has feathers, call it a duck. If the patient’s prognosis and plan is death, even if one can gin-up Part A coverage, don’t do it. First, the act of providing non-medically necessary care or care not warranted (inverse coding) is an act of fraud and a violation under the False Claims Act. Similarly, over-treatment and unnecessary care may bring professional sanctions for licensed individuals as well. Essentially, an ethical problem of a large degree is present. Of course, if the patient has consented to a course of curative or interventional care as a last shot at improvement or in an effort to re-build strength/stamina prior to a wedding, family event, etc., the services are warranted and should be properly billed to the Part A SNF benefit. Quite honestly, what I see routinely is the latter is the outlier. The “skilled until death” driven by cost is the norm and this one is perilous for those who play the game. Auditors are out there and this “phenomenon” is known to the OIG and as it grows, scrutinized. Remember, coverage is determined by the legitimate medical needs of the patient, as determined by assessment and framed by the goal/determination and consent of the patient (and/or his legal surrogate). If this does not warrant the use of daily skilled services/interventions to achieve the goal of the patient and meet his/her legitimate care needs as assessed, no coverage is available under Part A. Going beyond this prior point in search of coverage is an act of achieving payment for non-warranted, non-necessary services and as such, a violation of the False Claims Act.
2 Comments »