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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, October 24, 2011 Posted in: Inpatient Rehab

Recently, I answered a question on the RehabNurse List Serve and I wanted to share the information with you because I felt it would be very beneficial for many Mediware Blog post subscribers.

A nurse requested information on outcomes and the ability to provide documentation to a Medicare HMO (Part C Plan) that rehabilitation vs. skilled care is most advantageous. Let me preface all this by saying every decision is individual, but that more often than what’s being advocated. Patients that have access to an inpatient rehabilitation stay are often denied because we, as professionals, do not take the time to educate and advocate when we have screened an appropriate patient and a payer does not agree. Admissions must be ready with information, facts and outcomes so that patients can access an appropriate level of care.

In 2007, when CMS asked for input on 1551-P, prior to publishing the final rule, one of the largest responses to a proposed rule flooded CMS. The first document contains very good articles to support rehabilitation over skilled care in appropriate patients. Some of the recommendations in these documents were enacted. Please note, when opening the links below that contain page numbers, you will need to open them in Adobe to access a corresponding page.

https://www.cms.gov/eRulemaking/downloads/CMS-1551-PPaperComments7-13.pdf  (Pages 134 to end)

Specific discussions on sufficient nursing services and outcomes comparisons start around these pages.

Pay special attention to sufficient nursing services for the patient you are trying to admit. The Medicare Compare website for SNFs can easily tell you the expected average for patients in your area, then you can discern whether the needs of the patient you are trying to admit can be handled with the care averages published.

https://www.cms.gov/eRulemaking/downloads/CMS-1551-PPaperComments3-6.pdf (Pages 59-60, list evidence-based research)

This link may also be helpful, available at CMS.gov

https://www.cms.gov/InpatientRehabFacPPS/09_Research.asp  (Bottom of page, PDF # 2)

Most important, with a CMS Part C plan, the plan must provide the same access to care as original Medicare would. I used this process when I managed the admissions office at an IRF where I was the director of rehab.

Go to this link and familiarize yourself with what is expected of Medicare HMO products. Because they are required by contract to cover all of the services original Medicare would cover, they must also utilize 2010 guidelines when distinguishing which patients are appropriate for access to care.

http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx

“What Does a Medicare Advantage Plan Cover?”

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers, except hospice care. Original medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).”

(These plans can offer more, not less than a beneficiary normally has access to.)

The route we took was to talk to the physician in charge of the plan. Send a copy of the pre-admission screening document demonstrating all of the criteria being met for rehab admission. (When I did these, we had the HCFA-85-2 ruling. Now it’s the 2010 Coverage criteria.) Given a physician signature on that document also attesting that the coverage criteria and the need for rehabilitation exists for the patient you are advocating on behalf of, Medicare HMO plans should reconsider access.Using your own outcomes for a particular population can also be very convincing. You want to be sure that your ducks are neatly in a row and that you adhere very tightly to all other criteria and timelines, or they will just as quickly play the same game and deny payment just as original Medicare would if criteria is not followed! I cannot stress that enough.

In addition, you have another recourse. All patients, before being discharged from acute care, by law must be provided the 72 hour notice when they are Medicare Beneficiaries.That notification tells them how to apply for a fast appeal regarding decisions for discharge. The patient/caregiver must then follow the instructions and state they have been notified that discharge to a rehabilitation facility has been advised and the Medicare Part C program is denying access. This is an appeal, and not a grievance. The quality organization for that area will then gather all the information. Make sure the discharge planner, or whoever is responsible for providing information to the quality organization, has a copy of the pre-admission screening along with the physician recommendation.Chances are very good that the quality organization will make a recommendation. All evidence from that interaction can then be forwarded to the Part C provider.

We must take the time to educate and provide the details necessary to provide appropriate services for our patients. Generally, patients don’t have this level of knowledge into our very complex systems – each and every one of us is responsible for advocating appropriately. This is one of my soapboxes! Pardon the length of this post.