RE: Break in Skill

[Doyle, Renee]

Had a similar situation:  Resident from a long-term care facility who had exhausted her benefits (over a year before) due to G-tube had 3 day hospitalization for unrelated reason.  She was Medicaid-Exceptional Care status at the nursing home.  I verified the info with the nurse, the billing department, and the MDS Coordinator at the nursing home.  She had Medicaid only.  We are hospital-based and are not Medicaid approved.  I tried to no avail to get the hospital care managers to understand that the patient had no Medicare coverage.  Unfortunately, the nursing home had not submitted a no-pay bill and the medicare computer showed she had full benefits.  Our insurance verifier called the FI (so I'm not sure how she explained the situation) and was told to bill anyway.  Of course we have been paid, because computers don't know when humans make mistakes.  So now the care managers feel justified sending anyone they want because we will get paid as long as the computer shows they have days, even if it's wrong!   By the way, the patient also lost her exceptional care status because they didn't do the required screening in the hospital.  We had quite a time getting the nursing home to take her back, and she had been there 19 years!  In my opinion, if we know she doesn't have benefits, we are not supposed to bill Medicare.  I know it's not our fault the computer is wrong, but we shouldn't have billed.  Just because you can get paid, doesn't mean you should get paid.  I'm sure if there is an audit done by the FI, we will be returning the money!

-----Original Message-----
From: Maria2354 [mailto:[EMAIL PROTECTED]
Sent: Wednesday, November 19, 2003 7:08 PM
To: AANAC
Subject: Break in Skill

I would like to run this one by the group:

 

Several months ago, I made my corporate MDS Consultant aware that a resident could not be skilled again under Medicare A after benefits were exhausted for G-T tube if the resident remained in this or any LTC facility with feedings/flushes via G-T, meeting the skilling requirements, of course.  However, she recently recommended that my facility should submit a "Demand Bill" to the FI if we had a resident that would be skillable under Medicare A again although the resident did not have a break in skill. She stated that she had received this advice from the FI of another state. My facility is located in FL, so, if there is anyone from the FL FI participating in this group, I would appreciate your point of view on this issue.

 

Thank you in advance,

 

Maria

Maria Benton, R.N., C., C.N.A.C.,
MDS Coordinator

Jacksonville, Florida

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