IN regards to the resident, I wouldn't skill her for her daily injections, but becasue of the injections she is at a medicaid skilled level. This resident also needs 5 days of therapy. The problem was the HMO only granted us 3 days a week for two therapies. AS far as we know we do not have a contract for skillable services with this HMO company. Dawn Sheppard, RN, CRNAC ----- Original Message ----- From: "Anne Burrows" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Tuesday, February 03, 2004 1:02 PM Subject: RE: HMO to PPS
> On your other post you asked what rules HMOs have to follow. If you are > talking about a Medicare HMO (Medicare + Choice), they must provide whatever > would be covered by Medicare, plus whatever else the particular plan offers > its members. For the latter, it is best to have this clear in your > facility's contract with the HMO. For source information on this, go to the > CMS.gov site and read the electronic publications that are written for > consumers about the various Medicare plans. They are helpful because they > are written for lay people, and clearer than some other publications. They > make it clear that Medicare HMOs have to cover whatever would be covered by > Medicare. > > I sense that the woman in this post is the same one you were concerned about > in your earlier post. I question whether the daily injections would in > fact entitle her to use her Medicare skilled benefit. Does she need to be > in a SNF to get the injections? Is there some area of skilled monitoring or > judgement there that would require her to be in a SNF and entitle her to use > the benefit? Therapy 3x a week doesn't add up to a daily skilled need > either. Possibly it is one of those extras the HMO offers its members, and > if so, it should be in your contract with the HMO. > > About the disenrolment and return to regular Medicare: The day of the > switch is day 1 for figuring the PPS schedule. I don't know when she > actually disenrolled, of if you are still in the window for when it is legal > to do the 5-day, 14-day, etc. If you are still within bounds, OK. If not, > you can bill at the default rate. > > If a SNF resident disenrolls from a Medicare HMO and picks up traditional > Medicare, this is in a way a continuation of a Medicare stay, because the > government is paying the HMO for the coverage. So you don't have to be > within 30 days of the qualifying hospital stay at the time of the switch. > On the same token, the days covered by the Medicare HMO count as part of the > 100 day benefit. > > This is how it works, but I am not convinced your resident has a daily > skilled need that entitles her to use Medicare. > > > >From: "sheppard70057rn" <[EMAIL PROTECTED]> > >Reply-To: [EMAIL PROTECTED] > >To: <[EMAIL PROTECTED]> > >Subject: HMO to PPS > >Date: Mon, 2 Feb 2004 18:27:03 -0600 > > > >I have a question in regrds to HMO to PPS. > > > >Had a resident admitted from hospital 12/30/03. Attempted to get a skilled > >rate from HMO on this resident but they denied it. However technically > >this resident would be at a SNF level, not an ICF level due to daily > >injections. Then January 16, 2003 the HMO company gave us authorization > >for PT and OT to treat 3 x week. They treated for two weeks and now it is > >time for reauthorization, however, we found out today that she disenrolled > >from HMO and now is Medicare Part a and b. Can we pick her up for PPS now? > > This resident's hospital stay was for COPD and exacerbation of CHF. WE > >had been requesting therapy from the time she came to our building but the > >HMO drug their feet and did not give authorization for almost 2 1/2 weeks. > > > >I called the FI, and they do not know. The representative I talked to said > >she has to ask someone else and they will get back with me. Does anyone > >out there know. > >Dawn Sheppard, RN, CRNAC > > _________________________________________________________________ > Let the new MSN Premium Internet Software make the most of your high-speed > experience. http://join.msn.com/?pgmarket=en-us&page=byoa/prem&ST=1 > > /---------------------------------------------------------- > The Case Mix Discussion Group is a free service of the > American Association of Nurse Assessment Coordinators > "Committed to the Assessment Professional" > Be sure to visit the AANAC website. Accurate answers to your > questions posted to NAC News and FAQs. > For more info visit us at http://www.aanac.org > -----------------------------------------------------------/ /---------------------------------------------------------- The Case Mix Discussion Group is a free service of the American Association of Nurse Assessment Coordinators "Committed to the Assessment Professional" Be sure to visit the AANAC website. Accurate answers to your questions posted to NAC News and FAQs. For more info visit us at http://www.aanac.org -----------------------------------------------------------/
