We recently received the outcome of our TPE audit. The MAC denied even with our delayed certifications for the skilled stays. We thought this was an accepted process if the SNF certification / recertifications were late. How can we dispute the determination?
According to Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, “Physician Certification and Recertification of Services,” §§40.5, delayed certifications and recertifications will be honored where there has been an isolated oversight or lapse. The facility must be able to show that specific case(s) which required the delayed certification and/or recertification for the skill stay was in fact isolated. You should also validate the delayed certification includes an explanation for the delay. For example, did COVID or the PHE impact the need for delayed certification? Be sure to include any medical or other evidence the facility considers relevant for purposes of explaining the delay.
- The certification must clearly indicate that posthospital extended care services were required to be given on an inpatient basis because of the individual’s need for skilled care on a daily basis for an ongoing condition for which he/she was receiving inpatient hospital services prior to transfer to the SNF (or for a new condition that arose while in the SNF for treatment of that ongoing condition).
- The recertification statement must contain an adequate written record of the reasons for the continued need for extended care services, the estimated period of time required for the patient to remain in the facility, and any plans, where appropriate, for home care.
- A statement reciting only that continued extended care services are medically necessary is not, in and of itself, sufficient.
For more information on SNF certification process, access our previous blog Avoiding Common Errors on SNF Certification/Recertification