ABN and NOMNC
Question and Answer Series
Question: If we issue a notice on 7/12 to be effective 7/15. Resident appeals to the QIO on 7/15. QIO denies appeal on 7/17 and resident discharges home on 7/18. We continue skilled services beyond our initial end date as indicated on the notice while waiting on the QIO decision. Can we bill through the date of discharge since we were required to continue services while waiting on the appeal decision?
Answer : With an expedited determination filed, the provider may not bill a beneficiary until the review process is complete. You cannot bill Medicare if the patient no longer meets skilled criteria. When the NOMNC is issued by the SNF and the beneficiary or their representative disagrees with the termination of skilled services, it is their responsibility to contact the BFCC QIO no later than noon of the day before coverage ends for an expedited review. The beneficiary, the beneficiary’s physician, and the provider should be notified by the QIO no later than 72 hours after the receipt of the request.
The NOMNC states that the beneficiary may have to pay for any services received after the date that coverage ends. It states that if the beneficiary stops services no later than the effective date on the NOMNC then they will avoid financial liability. If the QIO agrees with the provider that services should no longer be covered, then neither Medicare nor a Medicare Advantage plan will pay for those services after the effective date on the NOMNC. The SNF ABN will identify the cost of care if the beneficiary’s appeal is declined and the beneficiary is going to stay beyond the last covered day, allowing the beneficiary to make the financial decision about continuing care.
Question: Please clarify when ABN should be given for Medicare Part B. We are doing it 48 hours before the end of therapy as we are not sure as to the number of services unless the patient has been evaluated and had some treatment already.
Answer: The NOMNC is delivered close to the end of treatment, either on or before the second to last day of treatment before the termination of all Medicare Part B or Part C (Medicare Advantage) therapy services in an SNF.
The ABN (Form CMS-R-131) is only issued to Medicare Part B beneficiaries who want to continue, initiate or increase therapy that Medicare is unlikely to pay for or those who need an official Medicare decision to file a claim with secondary insurance (Option 1 is chosen in this instance). If the beneficiary wants to continue therapy services that are considered custodial care, experimental “research only” or are not reasonable and necessary, the ABN informs the beneficiary (or their representative) that Medicare is not likely to cover the services and it allows them to make an informed decision about accepting financial responsibility if Medicare does not pay for them. Delivery is required before rendering Part B services that are unlikely to be paid for by Medicare and should be issued far enough in advance to allow sufficient time for the beneficiary to consider all available options.
- Question: If we have a physician order for therapy and it's medically necessary, we don’t need to give Med B ABN?
Answer: Correct, if the patient meets Medicare skilled coverage criteria.
- Question: Do you have to give an ABN to a resident going on Hospice if they are not terminally ill?
Answer: A SNF is not responsible for the delivery of beneficiary notices to a resident who chooses to elect hospice.
- Question: Will ST alone skill a patient?
Answer: Yes if skilled Speech Therapy is reasonable and necessary and rendered 5 days per week. Kris B. Harmony highly recommends that nursing assess and document the reason why Speech Therapy is needed, document that as a practical matter that the daily skilled services can only be provided on an inpatient basis in an SNF, and the relationship of the Speech Therapy services to the hospital stay or the condition that arose while skilled.
- Question: If a resident is covered under Medicare A and admits to hospice unexpectedly (meaning not with a 2-day notice), is the NOMNC still needed? The facility is not saying that the resident no longer meets skilled criteria, the resident is electing to come off skilled services.
Answer: No, there is no beneficiary notice required when a resident elects hospice.
If the resident is electing to choose hospice and the reason for hospice is related to the reason for skilled care, then no beneficiary notice is needed as it is the resident deciding to end the skilled services. If the reason for skilled care is unrelated to the reason for hospice and the patient is continuing with Part A services and hospice, no beneficiary notice would be issued.
- Question: Can you please explain why we are issuing an ABN (if MCR days remain) and the patient remains in the facility, electing Hospice Care? The patient is electing to discontinue therapies/skilled care to pursue Hospice, so no NOMNC but ABN?
Answer: There is no required beneficiary notice (NOMNC, SNF ABN, or ABN) when the patient elects hospice. An SNF ABN could be given as a voluntary notice, however, Kris B. Harmony recommends that you consider creating a voluntary notice that is streamlined for this purpose and easily understood. Kris B. Harmony can assist you with this.