Effective July 15, 2022, HHS Secretary extended the PHE, the new expiration date being October 13, 2022. CMS continues to recognize that disruptions arising from a PHE can affect coverage under the SNF benefit:
- Prevent a patient from having the 3-day inpatient QHS
- Disrupt the process of ending the patient’s current benefit period and renewing their benefits
While providers may continue using the QHS and Benefit Period Waivers, documentation needs to support how the skilled stay relates to the PHE, and in the absence of the pandemic, that the skilling condition would have required an inpatient hospital stay.
Reviewing the March 13, 2020 letter to HHS from CMS Administrator which states, “SNF care without a 3-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are otherwise affected by the emergency, such as those who are (1) evacuated from a nursing home in the emergency area, (2) discharged from a hospital (in the emergency or receiving locations) in order to provide care to more seriously ill patients, or (3) need SNF care as a result of the emergency…” The letter goes on to explain that the benefit period waiver “will apply only for those beneficiaries who have been delayed or prevented by the emergency itself…”
Notably, Proactive has seen recent medical review activity from the Supplemental Medical Review Contractor (SMRC), Noridian. Their current project reports that data analysis done by CMS and the SMRC identified a potential area of vulnerability, and the SMRC is tasks to perform medical review on SNF claims (3/1/2020 – 12/31/2021) that had zero hospital days prior to admission.
To avoid potential denials, the IDT should determine and document:
- What the skilled service(s) is/are,
- How SNF level of care is met,
- How the skilled stay relates to the PHE,
- An inpatient hospital stay would have likely been necessary to manage the condition(s) in absence of the pandemic (QHS Waiver),
- The PHE prevented the beneficiary from beginning/completing the 60-day break (Benefit Period Waiver).
According to AHCA (A12), “the QHS waiver can be used multiple times for the same beneficiary in the following situation: The beneficiary has had a 60-day break since the last day requiring a SNF level of care. Therefore, other than the one-time spell of illness waiver option, the QHS waiver in itself is not renewable. However, once the beneficiary has had a 60 day or more “wellness period”, then he/she would be eligible for a subsequent QHS waiver under a new benefit period.”
Remember, these measures don’t waive or change any other existing requirements for SNF coverage. As a safeguard, it is essential that all providers are specific in documentation on a case by case basis to clearly indicate how the decision for use of the waiver is directly related to the PHE in addition to continuing to focus on the individual skilled need and medical necessity requirements.
