Skilled Nursing Facility Medicare Covered

Medicare Coverage For Skilled Nursing Facilities

Skilled Nursing Facilities—or better known in the jargon of Medicare as SNF—is the cause of much consternation among people on Medicare.  The reason for the distress and stress is because Medicare beneficiaries are sometimes denied coverage.  This both confuses and angers Medicare beneficiaries because there doesn’t seem to be any rhyme or reason to the denials.  People ask: does Medicare cover Skilled Nursing Facility?

Medicare Billing Guidelines For Skilled Nursing Facility

From my observation over the years, doctors’ offices sometimes don’t follow the Medicare billing guidelines for Skilled Nursing Facility.  I understand everyone is busy and people are certainly well-intentioned, but Medicare is insurance.  Insurance has rules, protocols, and forms.  A lack of adequate explanation to Medicare is many times the cause of Medicare denials, I’ve seen over the years.  Other times the situation does not meet the Medicare criteria for Skilled Nursing Facility stays.

What are the Medicare Skilled Nursing Facility Requirements?

When skilled nursing is prescribed, five Medicare Skilled Nursing Facility requirements must be met.  The first is a qualifying hospital stay.

The Medicare beneficiary must stay as an inpatient for three consecutive days in the hospital.  Each of these is an essential ingredient.  The beneficiary must be admitted to the hospital.  If the patient is only admitted for “observation,” she will not qualify.  She must be an “inpatient.”  Next, the stay must be consecutive.  It can’t be a day or two within a short period of time.  It must be at least 3 consecutive days.  And finally, it must be at least 3 days, not counting the day of dismissal.

Many times, people assume the day of dismissal counts, but that is definitely not the case.  Three days of inpatient care at least with a fourth day for the dismissal.  Sometimes people will complain that the patient doesn’t need a third day, but if you want the person to qualify, she must stay at least three consecutive days.

Medicare Skilled Nursing Facility Benefit Period

The second ingredient for Medicare to cover a skilled nursing facility stay is the admittance must occur with 30 days of dismissal from the qualifying hospital stay.

My mother-in-law had open heart surgery a while back.  Her cardiologist prescribed that she stay in a skilled nursing facility for cardiac rehab.  She was not a very cooperative patient.  She refused.  My wife was insistent and explained that if she didn’t go then, she would lose the opportunity for skilled nursing rehab.  My mother-in-law’s response was she would do it later if she needed it.

Many people mistakenly think they can go to a nursing home for rehab if they simply want to.  It must be within the 30-day window after dismissal from an inpatient stay.  Otherwise, Medicare will not pay.  Now you may think it is not fair, or right, or make sense.  I am simply stating the rules and facts.

Medicare Guidelines for Skilled Nursing Facility

The third requirement for admittance to a skilled nursing facility (SNF) is the treatment can only be provided by a skilled nursing facility.

What this usually means is “full time” or five day a week care.  In other words, the same level of treatment cannot be provided by going to a treatment center by appointment a few times a week.  Only an inpatient skilled nursing facility can provide the level of intense treatment needed for adequate recovery.  This can be a tricky call and where judgments can and are questioned.

Medicare Denial Skilled Nursing Facility

I had a client who had a knee replacement.  Usually a knee replacement, even with complications, does not require admittance to a skilled nursing facility (SNF) because physical therapy is something that can be completed by going to the physical therapist’s office and/or doing exercises on your own.  This situation was different.

She was living in a small apartment with lots of furniture.  There was a pet.  The husband was feeble.  While she was not very old, her knee was not recovering at the usual pace.  The doctor recommended skilled nursing care, but Medicare denied the prescription.

The family came to me with questions.  I suggested they explain the situation to the doctor in greater detail and with more urgency.  She was a serious “fall risk” because of her living situation.

Once the idea was emphasized sufficiently in the doctor’s notes to Medicare, Medicare understood that the work that had been done would be undone if she fell at home because of a pet, furniture, and/or feeble husband, etc.  The request was approved.

Skilled nursing is very expensive.  Medicare needs to understand the “medical necessity” of a prescription.  Once the idea is communicated effectively, things can happen.

List of Medicare Approved Skilled Nursing Facilities

The fourth ingredient is that a doctor, or another appropriate medical professional, certifies that the patient needs the type of daily therapy that can only be performed in a skilled nursing facility.  The skilled nursing facility must also be a Medicare-certified skilled nursing facility.  You can go to Medicare.gov to find certified sites and Medicare the star ratings for Skilled Nursing Facilities.

The fifth and final requirement can be confusing.  The skilled nursing care must be for the reason the patient was in the hospital for the three days.

Imagine John goes to the hospital because of a broken hip.  While John was in the hospital, he has a stroke.  The doctor certifies John for treatment at a skilled nursing facility for the stroke, not the hip issue.  The skilled nursing recommendation does not have to be based on the reason the person was admitted to the hospital, but it does need to be because of something he was treated for during the 3-day hospital stay.

As you can see, Medicare coverage for skilled nursing facilities can be complex.  It’s important to have some understanding so that you know what to expect, or not to expect, when it comes to Medicare coverage of skilled nursing facility care, and how to navigate the processes to your benefit and the benefit of loved ones.  Medicare Part A covers the Skilled Nursing Facility, but the rule must be followed for Skilled Nursing Facility Medicare reimbursement to happen.