R2: The Low Down on Medicare Non-Coverage Notices

(The following is an advertorial featuring Park Place sponsor and thought leader R2 – Reimbursement Reimagined, a division of Zimmet Healthcare Services Group employing more than 300 staff. R2 offers remote MDS and case management solutions for accurate Medicare, Medicaid, and Medicare Advantage reimbursement. Amy Goldsmith, chief operating officer, leads the group.)

The following information is the work of R2’s Katy O’Connor, vice president of case management services, and Michele Stern, director of clinical education and training.

Please tell our readers about the ins and outs of Medicare Non-Coverage notices. 

When a Notice of Medicare Non-Coverage is issued, the patient should be at a level where, according to Medicare guidelines, they no longer meet the medical necessity requirements for inpatient care at a skilled nursing facility. However, we are finding that managed care organizations do not always align with traditional Medicare guidelines.

One example is the management of a new feeding tube. Under traditional Medicare, a patient with a new feeding tube can be covered for up to 100 Medicare days. Under many managed care organizations, however, the feeding tube is considered a skilled service only during the initial weeks when adjustment and management are actively taking place. Once the feeding tube has stabilized, these organizations often no longer consider the service skilled.

We also find that managed care organizations have a different threshold for determining what services can or cannot be provided safely in the community. Because of these differences, clear and thorough discharge planning documentation becomes essential.

Is there anything to inform on the role of the QIO?

The Quality Improvement Organization (QIO) also looks for updated discharge planning notes during any review. If discharge planning documentation is missing, the QIO may overturn the non-coverage determination. We are finding a disconnect in these situations because managed care organizations often consider this a technical overturn rather than a clinical one. In other words, the overturn is based on insufficient documentation rather than a clinical justification for continued skilled care. As a result, providers may be administratively denied payment for additional days because required procedures and documentation were not completed in accordance with provider agreements.

The QIO operates on a queueing system using a first-in, first-out process. Sometimes reviews move quickly and a determination is made the same day. Other times, there are delays, and decisions take longer. Preparing discharge planning for every possible appeal outcome allows facilities to remain proactive rather than rushing to develop a plan at the last moment.

What role does the R2 team play?

Our team pulls documentation immediately, allowing records to be prepared for upload within minutes of learning that a beneficiary has initiated an appeal. We have also observed trends across various states in how QIOs conduct their reviews. It is paramount that skilled documentation is organized, complete, and clearly identified for the QIO reviewer. When documentation packets become excessively large, important information can be overlooked. Reviewers may read one section while inadvertently missing critical details elsewhere in the record.

Document it all!

Discharge planning should begin on the day of admission and continue throughout the patient's stay. Staff members frequently communicate with patients, representatives, outside support systems, home care agencies, and medical clinics to determine what services will be available after discharge. However, these communications are often not documented. Delays involving durable medical equipment (DME), pending insurance approvals, equipment ordering, or home delivery should all be documented in the medical record, as this information can support a more favorable appeal outcome.

There is also disappointment with the recent Notice of Medicare Non-Coverage or NOMNC update because it does not include a clear section for documenting verbal notification of the beneficiary or nominee. While some managed care organizations provide their own documentation forms, we have found that certain versions omit key information that should be documented during a telephonic notification for the QIO.

During these notifications, providers should document not only the last covered day but also the date on which financial liability begins. Patients or their representatives must also be informed of their appeal rights and the time frame for requesting an expedited appeal.

Please explain why documentation goes to a representative.

Documentation should also explain why the notice is being presented to a representative rather than directly to the patient. The NOMNC refers to either the beneficiary or the representative. However, many managed care organizations require documentation identifying whether the individual signing is a power of attorney or healthcare power of attorney. They often expect documentation explaining why that individual signed on the patient's behalf, even though state surrogacy laws may permit another authorized representative to do so.

Some managed care organizations distinguish between healthcare and financial decision-making authority, asserting that financial decisions fall outside the scope of a healthcare proxy. This interpretation appears to extend beyond the CMS guidelines, which simply specify that a designated representative may sign on behalf of the patient.

Comments or questions on this article? Contact Patrick Connole at pconnole@parkplacelive.com.