02/08/2017
You Asked....We Answered
This week's You Asked..We Answered questions discuss the three day hospitalization issue and oxygen and DME charges.
You Asked:
A local hospital is wanting to send clients without a three day hospitalization. Has this legislation passed permitting admission without a three-day stay? Our facility is a 4-star but is not in a bundle with that hospital. Can the hospital still send a patient and can we bill Medicare?
We Answered:
LeadingAge Ohio reached out to its partners at LeadingAge, which provided the following information:
The three-day stay can be waived when a hospital is in the Bundled Payment for Comprehensive Joint Replacement (CJR) or certain Accountable Care Organizations (ACOs) have requested this authority. The hospital can only waive the 3-day stay and still have a qualifying skilled nursing facility (SNF) stay in cases where they refer to SNFs with a 3-star or higher star rating from the Centers for Medicare and Medicaid Services (CMS). So, the questions the member should ask are:
1) Is this a for a lower extremity joint replacement under the CJR bundle? Or a Model 2 Bundle Payment for Care Improvement (BPCI)? (If BPCI, what DRGs/conditions are covered by the bundle and does this align with the discharge for this particular patient);
2) If no, under what authority is this being done (e.g., ACOs, Medicare Advantage)? Medicare Advantage plans can also waive the 3-day stay requirement.
Depending on the ACO, they may need a preferred provider contract in place with the SNF to be eligible for the 3-day waiver. (E.g., Next Gen ACOs). For Pioneer ACOs, that waiver is granted via a contract with CMS.
You Asked:
I have a question regarding Oxygen and DME charges. Currently when we have a resident who is private pay that receives oxygen, we pass the charge onto the resident. Our billing company is telling us that the skilled nursing facility (SNF) should cover all charges of DME for all residents. This all started from a resident that was requesting a denial letter from the insurance company so that he could submit it to be reimburse from a different account.
We Answered:
Stephanie Dewees, LeadingAge Ohio’s Quality & Regulatory Specialist for Long-term Care, provided this answer:
This is a confusing issue, partly because of each payor's criteria and definition of "home". You can bill private pay, but you need to be consistent across all payors. Here is a detailed explanation.
DME and Oxygen cannot be billed to Medicare Part B if a resident resides in a skilled nursing facility. DME and Oxygen can only be billed to Medicare Part B if the beneficiary resides at home and a skilled nursing facility is not considered their home even if they are long term. Skilled nursing facilities and hospitals are not considered residential homes for the purpose of billing DME to Medicare B.
That being said, if DME or oxygen is being supplied in a nursing facility, then it would be looked at by payor. For a skilled resident covered under Medicare Part A it would be considered under consolidated billing, that would be the same for a resident that is under skilled care covered by a Managed Care or Insurance. If a resident has Medicaid then it would be considered part of the Medicaid rate, and it would be contracted off for those residents. If the resident is self-pay then they would be billed for the services. In some instances for self-pay residents they may have a secondary insurance that may pay for DME or oxygen while the resident is in the nursing home. Some insurances follow Medicare guidelines but some insurance may pay for the services the provider or resident would have to inquire with the insurance provider.
DME and oxygen services are not typically considered part of routine room and board costs. A facility does need to make sure they are billing all payors the same. For skilled residents and Medicaid residents those supplies would then be a contractual adjustment.
In the You Asked...We Answered section, LeadingAge Ohio staff share technical questions and advice that have been asked of them by members.
If you have a question you would like to see featured in You Asked..We Answered, email Nisha Hammel, Director of Advocacy at nhammel@leadingageohio.org , or Anne Shelley, Director of Professional Development & HH/Hospice Regulatory Relations, at ashelley@leadingageohio.org.
