At Broad River Rehab we love to engage our communities with shared knowledge. Long term care is a complex industry and we are constantly learning from each other.
We also love to engage the broader SNF community through a resource on our website we call Ask Our Experts. From time to time we get questions there that are challenging and helpful.
Recently we answered a question that we thought would be something you would like to know about.
Here’s the conversation
Question: I have a question. A patient gets admitted to SNF with Managed MCR as Primary Insurance without 3 day hospital stay. The patient then disenrolls from the Managed MCR plan and becomes Traditional MCRA. Can we Bill MCR since there is no 3 day hospital stay?
Answer: The short answer is yes, but only in some circumstances. Only in the circumstance where a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an inpatient in an SNF and converts to original Medicare (i.e., fee for service) will the requirement for a three day hospital stay be waived only if the beneficiary meets the level of care criteria found in 42 CFR 409, Subpart D, up through the effective date of dis-enrollment.
In Publication CMS 100-4 Medicare Claims processing Manual, Chapter 6 Inpatient Part A Billing and SNF Consolidated Billing section 90.1., CMS states the following. Please note the billing requirements!
90.1 – Beneficiaries Disenrolled from MA Plans
(Rev. 1618, Issued: 10-24-08, Effective: 04-01-09; Implementation: 04-06-09)
If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an inpatient in a SNF and converts to original Medicare (i.e., fee for service) the requirement for a three day hospital stay will be waived if the beneficiary meets the level of care criteria found in 42 CFR 409, subpart D, up through the effective date of dis-enrollment. The beneficiary will then be eligible for the number of days that remain out of the 100 day SNF benefit for that particular SNF stay minus those days that would have been covered by the program under original Medicare while the beneficiary was enrolled in the risk MA plan.
However, in cases where the beneficiary disenrolls from a risk MA plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day rule, all requirements for original Medicare (i.e., fee for service), including the 3-day hospital stay must be met. Rules regarding cost sharing apply to these cases. That is, providers may only charge beneficiaries for SNF coinsurance amounts.
If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet all original Medicare requirements for a SNF stay, including that of a three day inpatient hospital stay. SNFs submit all applicable fee-for-service inpatient SNF claims with condition code “58” to indicate a patient was disenrolled from an MA plan and the 3-day prior stay requirement was not met. Claims with condition code 58 will not require the 3-day prior inpatient hospital stay. The A/B MAC (A) must use CWF files to validate the beneficiary was enrolled in an MA organization upon admission to the SNF and that the MA enrollment period ended prior to the “from” date on the claim. The A/B MAC (A) does not need to verify that the MA plan was the one that terminated.
Do you have a question? Give us a shout and Ask an Expert!