Protecting Your Skilled Nursing Facility Benefits: What Every Medicare Beneficiary Should Know

As a contractor for Medicare, Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, also referred to as a BFCC-QIO. While Acentra Health provides BFCC-QIO services in 29 states, the general information is relevant to everyone who has Medicare (including Medicare Advantage) and everyone who works with people who have Medicare. 

This episode is a conversation with our guest, Dr. Jessica Whitley, Chief Medical Officer for Acentra Health. She will share information about appeals and how you can protect your skilled nursing facility benefits.

For more information about Acentra Health BFCC-QIO, please visit https://www.acentraqio.com.

KEY TOPICS

00:24: Overview, introduction of Dr. Jessica Whitley

01:30: Who issues the Notice of Medicare Non-coverage?

06:28: What are skilled services?

10:19: Therapy participation

14:15: Medical record review

16:54: How you can help yourself in the skilled nursing facility

26:04: Final thoughts

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RESOURCES

BFCC-QIO Information for stakeholders: https://www.acentraqio.com/partners

BFCC-QIO Information for people who have Medicare: https://www.acentraqio.com/bene

BFCC-QIO Information for people filing an appeal: https://acentraqio.com/bene/appeal

Music: Motivational Upbeat Corporate by RinkevichMusic 

https://soundcloud.com/rinkevichmusic

https://protunes.net/

Video Link: https://bit.ly/3NNqGTs

Transcript

Welcome to Aging Health Matters, a podcast from Acentra Health, a Beneficiary and Family Centered Care Quality Improvement Organization. We plan to cover healthcare topics for the Medicare population. Information in today's show may help you or someone you know in their healthcare journey. Thanks for joining us. Now let's get started.  

Hello everyone, and welcome to Aging Health Matters. I'm Dr. Jessica Whitley, Chief Medical Officer for Acentra Health. Acentra Health serves as the Beneficiary and Family Centered Care Quality Improvement Organization, or BFCC-QIO for Medicare beneficiaries in 29 states. We help people with Medicare who have concerns about their health care. We can help you appeal if you believe you're leaving the hospital too soon or if skilled services like physical therapy are ending too early. We also offer Immediate Advocacy services to help fix problems quickly with medical care or services. More information is available on our website at acentraqio.com. That is A, C as in cat, E, N as in Nancy, T as in Tom, R, A, Q, I O dot COM.
 
Today, we're going to talk about something that affects thousands of Medicare beneficiaries every year, receiving a notice of Medicare Non-coverage. This is sometimes called a NOMNC, and that's because of the abbreviation, which is N as in Nancy, O, M as in Mary, N as in Nancy, C as in Cat. So you can receive a notice of Medicare non-coverage or NOMNC while being cared for in a skilled nursing facility. 

If you've ever worried that your therapy was ending too soon, or helped a loved one recover after a hospitalization, this episode is for you. My goal today isn't simply to explain Medicare rules. My goal is to help you become your best advocate. Because here's something I want you to remember throughout this entire episode. The best appeal begins long before you ever receive a Notice of Medicare Non-coverage. At Acentra Health, we review approximately 25 to 30,000 Medicare appeals every month. And there is a pattern that stands out. More than 80% of all appeals come from people receiving care in skilled nursing facilities. Even more striking and important is that the vast majority of these appeals come from beneficiaries enrolled in Medicare Advantage plans, or they're also called MA plans sometimes. One thing that surprises many beneficiaries is that who decides it's time to issue the notice of Medicare Non-coverage depends on the type of Medicare coverage you have.

If you have original Medicare, the decision is made by the healthcare team at the skilled nursing facility. They evaluate your condition and whether or not you continue to meet Medicare's coverage requirements. Alternatively, if you are enrolled in a Medicare Advantage plan, the process is different. Your skilled nursing facility still provides your care, and they send clinical information to your Medicare Advantage plan. But the health plan makes the coverage determination and decides when to issue the notice of Medicare Non-coverage. 

This difference is important because our experience reviewing appeals shows that beneficiaries enrolled in Medicare Advantage plans request appeals much more frequently than beneficiaries enrolled in Original Medicare. In fact, while the Medicare Advantage beneficiary population represents about half of the beneficiaries we serve, they account for over 90% of skilled nursing facility appeals that we review. So many beneficiaries and their families feel like they're being told Medicare coverage is ending before they are ready to leave. And receiving one of these notices can be frightening. You may wonder, am I ready to go home? What if I fall? What if I still need therapy? What happens if I disagree?

The good news is no matter what type of Medicare you have, Medicare gives you important rights, including the right to request a quick review of the decision to end your skilled nursing facility services, and you can appeal that Notice of Medicare Non-coverage. Now, before we talk more about the Notices of Medicare Non-coverage, it's helpful to understand when Medicare is supposed to continue paying for care in a skilled nursing facility and when coverage appropriately ends. Many people assume that Medicare pays simply because they still need help. But in reality, Medicare has very specific coverage guidelines. Medicare pays for skilled nursing facility care when you need skilled nursing services and/or skilled rehabilitation services on a daily basis. And when these services are consistent with standards of medical practice and when they are not simply for the convenience of the patient or the provider. 

So what does skilled mean? What does a skilled service? A skilled service means that the service requires the knowledge and skills of a licensed healthcare professional, such as a registered nurse, a physical therapist, occupational therapist, or a speech language pathologist. So these services are services that cannot be provided safely or effectively by someone without specialized training. Some examples of skilled services include complex wound care, IV medication administration, a professional assessment of changing medical conditions, therapy services when they are teaching patients how to regain the ability to walk, how to strengthen certain muscles that may not be working right, how to teach you to coordinate muscles together so that you can walk or balance safely after an acute illness has impaired your ability to move around or perform mobility activities safely. 

Now on the other hand, there's some very important services that are not generally considered skilled under Medicare rules. Examples of these are assistance with bathing, dressing, eating, combing your hair, just a little bit of help getting in and out of the bed, or taking your routine medications. These activities are all necessary for a person's well-being. And sometimes people may need assistance with these services. But these activities by themselves, generally do not qualify for Medicare skilled nursing facility coverage. They are not considered skilled services. And even if there is not a person available to assist with these non-skilled services, that doesn't make the services skilled. So although you may need help, Medicare does not provide payment for help for non-skilled services. It would be a service that you would have to pay for out of pocket. Now another point that I want to convey is that to get care in a skilled nursing facility, the skilled services must be needed and provided on a daily basis. 

Now that means two different things depending upon if you're getting skilled nursing services or skilled therapy services. If you're getting skilled nursing services daily, means you need those services seven days a week. However, if you're qualifying for a skilled nursing facility is based upon your therapy needs. Daily means five days a week. And that means five days a week, you need at least one of the therapy disciplines, physical therapy, occupational therapy, or speech therapy. You cannot combine the therapies to equal 5 days. If you needed physical therapy on two days and occupational therapy on three days, adding those together does not meet the daily requirement. The daily requirement must mean that you must need at least one of those therapy services five days a week, which would mean you would need
 physical therapy five days a week, or occupational therapy five days a week, or speech therapy five days a week.
 
Now, the good news is that Medicare does recognize that people recovering from illnesses or surgery sometimes have a bad day. So if you miss one or two therapy sessions because you're sick, in pain, or experiencing a temporary setback, that doesn't automatically mean that your Medicare coverage should end. Actually, Medicare policy recognizes that an occasional interruption in therapy may happen, especially when it wouldn't be practical or safe to discharge you because you are experiencing some type of medical setback. However, if you're unable to participate in therapy over a longer period of time, the reason matters. For instance, if you're refusing therapy or consistently choosing not to participate because you don't want to participate, you may no longer meet Medicare's coverage requirements for skilled rehabilitation services. 

Now, on the other hand, if you can't participate because you're ill or you've had some type of setback, you have increased pain, or if your condition has worsened, that tells a different story. You can meet, or you can even not meet the daily therapy requirement, but because your condition has changed, you may now need daily skilled nursing services to observe your condition
 and to treat accordingly, to monitor and evaluate what's happening with you. And to further determine if your condition has worsened to a point that you may even need evaluation to determine if you need hospital-level care. So remember, if pain, infection, shortness of breath, dizziness, confusion, or another medical problem prevents you from participating in therapy, make sure your care team knows exactly why you feel you can't participate that day and ask them to make sure they document that reason in your medical record. And that information becomes very important if your Medicare coverage is reviewed later.
 
Now let me tell you about one of the biggest myths about Medicare. It is that coverage ends simply because you're not improving. Let me just state that isn't true. Medicare may continue to cover skilled care when those services are needed to maintain your current condition or to prevent or slow further decline in your condition, or if you and/or your caregiver needs teaching and training to help you to learn to move around safely because you're not able to move around like you were before you became ill and needed the stay in the skilled nursing facility. The question isn't simply, am I getting better? The question is, do I still need skilled nursing or therapy that requires the expertise of licensed professionals? Understanding these guidelines will help you better understand why a Notice of Medicare Non-coverage may be issued and whether you should ask questions or request an appeal.

Now I'm going to share something with you that a lot of beneficiaries don't realize. When someone requests an appeal of a notice of Medicare non-coverage, our physicians at the BFCC-QIO perform a medical record review. We carefully review the medical record documentation submitted by the skilled nursing facility to determine whether Medicare coverage criteria continue to be met. Let me tell you what we cannot do. We cannot visit the facility. We cannot interview nurses or therapists. We cannot speak directly with the treating physician. We cannot observe therapy sessions. And generally, we cannot base our decision on information that is not documented in the medical record. Let me explain that a little bit further. You may call us and tell us, I'm not ready to be discharged because overnight I've developed significant nausea and vomiting, and I'm vomiting multiple times a day. It is possible that the records we get may not have information from the night before, they may contain information up to the day before your call. So we would take that into consideration that what you're telling us may not be recorded in the medical record yet, and therefore we do listen to what you are saying.
 
But it is important for you to realize this because the medical record is the primary source of information we use to make our decision. So if something important isn't documented, it may be very difficult for us to consider it during the review. That is why I encourage every beneficiary and family member to become familiar with their medical record. Know what's being documented in your medical record. If you have concerns about your progress, your therapy, your pain, your ability to walk safely, or any other important issue, ask your care team whether or not those concerns have been documented. And if appropriate, ask to review therapy notes, nursing notes, or care plan notes. You have every right to understand what your medical record says about your condition.
 
Now, let's talk about how you can help yourself every day while you're in the skilled nursing facility. One of the biggest mistakes that patients make is waiting until they receive a Notice of Medicare Non-coverage before becoming involved in their care. By then, much of the medical record has already been written. A lot of the care has already been rendered. Instead, I encourage you, I mean, I truly, truly encourage you and your family and/or your caregivers or friends to become active members of your healthcare team from the very first day. Ask questions. Know what are my care goals? Understand what your therapists and nurses are working toward. Every day is an opportunity to make sure you understand and agree with your care goals and to make sure your medical record accurately tells your stories.
 
One of the best ways to advocate for yourself is simply by asking questions. Here are some questions I encourage every beneficiary and/or their caregivers to ask regularly. What are today's therapy goals? How am I progressing compared to yesterday or compared to last week? If I'm having pain or difficulty participating in therapy, has that been documented? If I've improved today, what improvement was documented? Another question, what skills am I working on before I can safely return home? One of the most important parts of your care while in a skilled nursing facility is discharge planning. Discharge planning should begin on day one of your stay and not at the end of your stay. So ask, what needs to be done so that I can walk safely? Or if your healthcare condition prevents you from walking, then say, what needs to be done so that I can move around my home safely? Another question, what needs to be done so that I can transfer from the bed to a chair safely? Or what needs to be done so that I can safely use the bathroom?
 
If you believe you can't safely perform these activities, you want to ask your care team to explain when they believe you will be ready for discharge and what needs to be in place for you to be able to have a safe discharge. Ask them also to make sure this information is documented in the medical record. I also encourage beneficiaries and caregivers to keep a simple notebook during their stay. Write down how your therapy sessions went, any progress you notice, things that may be limiting your progress, such as days when pain may have limited therapy, or if you're having a hard time understanding instructions from the therapist. Record if you've had a fall or a near fall. Record any medication adjustments they may be making. 

Record questions that you want to ask so that you don't forget those questions the next time you see one of those team members. If you have any new symptoms or concerns about your help. Write those down so that you can remember to ask about that. And ask, you know, and record conversations that you've had with the care team. Record they expect me to be able to discharge in two weeks. Be sure you're talking to your family and/or your caregivers. Do we think I'm going to be ready? Are there things we need to get ready for me to be able to come home? Make sure you understand that the notebook doesn't replace the medical record, but it's there to help you remember important events and to ask important questions if something doesn't seem right, or just to make sure you're staying involved in your care every step of the way. 

Now, even when you're actively involved in your care, you may still receive a Notice of Medicare Non-coverage when you don't feel you're ready for discharge. If that happens, don't panic. Read the notice carefully and follow the instructions immediately. If you disagree with the decision, request what's called an expedited appeal as soon as possible. The notice is going to explain how to do that. The review will happen quickly, so acting promptly is very important.

When you call the BFCC-QIO for the appeal, give specific reasons why you feel you're not ready for discharge. Don't just say, I'm calling to appeal because I don't feel ready for discharge. Tell us why. For instance, say, I'm unable to walk short distances. I can't even walk to the bathroom, or I'm having significant balance problems, and I'm really at risk of falling, or I can't even transfer from the bed to a chair safely, or my medical condition has changed. I have a fever, or I'm having significant shortness of breath over the last two days.
 
Be specific when you're telling us why you feel like you're not ready to leave. And importantly, remember, tell us why you think you need daily skilled nursing services or daily therapy services. Make sure you think about that and give us specifics because those responses are written down and conveyed to the physicians that will review these appeals. Now, during an initial review, it's important to know that Medicare coverage continues while that expedited appeal is being decided upon, provided you request it within the required time frame. That time frame is going to be given to you in that notice. Make sure you don't miss that time frame so that you can have financial protection while the appeal is going on. And then, if you appeal and the QIO does not side with you and they agree with the Notice of Non-coverage. They agree that your condition no longer meets the Medicare coverage guidelines. 

Before you discharge, here's several questions I encourage you to ask. What are the therapy goals that I have met? What are the goals that I have not met? Am I safe to return home? What is my risk of falling? What is my risk of returning to the hospital? Can you explain why you believe I no longer need daily skilled nursing services or daily therapy? Can I review documentation supporting this decision? These conversations can help you and your caregivers better understand the decision and make sure everybody is working from the same information. If you did not win your initial appeal with the BFCC-QIO and you feel like you still need care in the skilled nursing facility, ask for a reconsideration of that initial appeal decision. The BFCC-QIO should give you instructions on how to file a reconsideration when you are given your initial appeal determination. You can also call the BFCC-QIO to ask how to file a reconsideration. 

And you can also tell the representative that you have serious concerns about the original appeal determination that was made, and you feel like you're not safe to discharge, and you can request to speak to a nursing supervisor. You can also, and this is something that a lot of people don't realize that we have at the BFCC_QIO, you can also ask for Immediate Advocacy, and they will transfer you to our Immediate Advocacy department where a nurse and or social worker will work with you to try to figure out what the barriers to discharge or what the things that are going on that may make you unsafe to discharge. And they can help to resolve some of those issues, or they can help to advocate for you if it appears that your clinical condition does continue to warrant Medicare coverage services in that skilled nursing facility. So don't forget to ask and request for Immediate Advocacy services to get assistance. if you really feel like you're not safe for discharge and you lost that initial appeal.
 
Finally, I want you to remember that it is so important that you look at yourself as a part of the healthcare team. Sometimes people think that health care happens to them. I want you to think completely differently. Health care works best when it happens with you, with you and your nurses, with you and your therapist, with you and your physicians, with you and your family, with you and all the members of the care team. The more informed you are and the more informed they are about your concerns and your goals, that helps to make the best care decisions. And that helps to make sure you get the best care possible. I'd like to leave you with one final message. The strongest appeals often begin with the strongest medical records. Don't wait until you receive a Notice of Medicare Non-coverage to become involved.

Ask questions from day one. Understand your therapy goals from day one. And this continues from day one throughout your stay. Know how you're progressing. Speak up if something changes and make sure it's recorded in your medical record. If pain, illness, significant fatigue, or another medical problem affects your therapy, make sure your care team knows about it. If you have concerns, ask whether they've been documented in your medical record and you can ask to review that medical record.
 
Remember that when the BFCC-QIO reviews an expedited appeal, we rely on the medical record to understand your story. By partnering with your healthcare team throughout your stay, you help to ensure that your medical record accurately reflects your condition, your progress, and your ongoing needs. It makes sure that your team understands your condition, your progress, your ongoing needs, your concerns. Finally, remember, you are not alone. If you need help understanding your rights, you can contact the BFCC-QIO. Remember our Immediate Advocacy department. You can contact 1-800-Medicare, or you can contact the Center for Medicare Advocacy.

Those are free services that can help you navigate certain care situations where you feel like you're not getting appropriate care or appropriate services. Now, if you found today's episode helpful, please visit acentraqio.com. That's A, C as in Cat, E, N as in Nancy, T as in Tom, R, A, Q as in Queen, I, O, and you can learn more about our services at that website. You can also sign up for our newsletter, subscribe to our YouTube channel, and you'll also find our contact information in today's show notes. Thank you so much for listening. Until next time, stay informed, stay engaged, and take an active role in your healthcare journey.