Days Awaiting Placement

Medicare HMO payers are not necessarily experts in Medicare regulations nor are national companies contracted to provide Medicaid benefits experts on each state's regulations. ARA isn't an expert in all aspects of these regulations either, but we do the research as patterns develop.

One such Medicare pattern most hospitals have encountered is the scenario in which a payer denies care after the acute phase is over even when a skilled nursing facility is warranted, but placement is delayed . Your clinical staff acknowledges this, the chart documents your efforts and placement delays, but basically you cannot get further authorization.

A CMS July 2006 provision found in the "Medicare Claims Processing Manual Chapter 3 - Inpatient Hospital Billing; 40.2.2 - Charges to Beneficiaries for Part A Services; C - Inpatient Care No Longer Required" states that:

…that the beneficiary no longer required inpatient hospital care. (For this purpose, a beneficiary is considered to require inpatient hospital care if the beneficiary needed a SNF level of care but an SNF-level bed was unavailable.) The hospital cannot issue a notice of noncoverage if a bed is not available. Medicare pays for days awaiting placement until a bed is available…

In the case of non-Medicare situations similar to the above where the payer refuses further authorization at the current level of care, we suggest you consider an ad hoc agreement (See "Ad Hoc" blog) for a lower level of care rate, unless the payer is simply wrong. For example in Texas if Child Protective Services extends a stay, out of state contractors do not always know that the hospital is entitled to 3 extensions of 5 days each.