A Lesson Learned on Retaining Inpatients Amid Waiting for a SNF

Will Medicare cover a day in the hospital when the patient is ready for discharge, but needs a skilled nursing facility (SNF) and no SNF bed is available?

The answer is a clear “yes,” but I didn’t realize just how clear until Eleanor from Virgina taught me. Here is a great reminder of the value of learning from others. 

Many years ago, I was asked if it was permissible to keep a patient in the hospital simply because no SNF bed was available.

At first, I was not sure. Then, I discovered some language in a manual I didn’t know existed. In Chapter 7, Section 7007 of the Quality Improvement Organization (QIO) Manual is text indicating that Medicare pays for days awaiting placement until a SNF bed is available. That was certainly helpful, and I included it in a presentation last week.

But to be blunt, my analysis was seriously deficient, and I didn’t know it. 

After the talk, Eleanor came up with some additional language from the Medicare Benefit Policy Manual (Chapter 1, Section 10.2,A.1.b) that says “if the reason an inpatient is still in the hospital is that they are waiting for the availability of skilled nursing facility (SNF) bed, the regulations at 42 CFR 424.13(c) and 424.14(e) provide that a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis.”

Regular readers are hopefully screaming “but David, manuals are not binding.” That is, of course, true. Both the QIO Manual language and the Benefit Policy Manual language are less-than-perfect citations. But note that the Benefit Policy Manual includes two citations to federal regulations. Let’s look at 424.13(c):    

“The physician may certify or recertify need for continued hospitalization if he or she finds the patient could receive proper treatment in a SNF but no bed is available in a participating SNF.”

That is extremely explicit language from a regulation that makes it perfectly clear that this person qualifies for hospital care if they are ready to leave, but they need a SNF and no nearby participating SNF is available. I will admit that I am embarrassed that I didn’t know about that text before, but I didn’t. The regulation refers to a “participating SNF.”

While I don’t believe “participating SNF” is defined in that portion of the regulation, “participating hospital” is defined as “the hospital that has a provider agreement to provide services in Medicare,” and I think it is quite obvious the term “participating SNF” is used as a mechanism to clarify that a bed in a facility that won’t accept Medicare doesn’t factor in the analysis. 

So, keep going to conferences and listening to webinars. Learn from others. Keep an open mind. I thought my talk was okay, but it could have and should have been better. It should have cited the regulation, not the QIO Manual.

But the good news is that thanks to Eleanor, I can now belt that love ballad from Survivor.

I no longer have to point to manual language and say “how can I convince you what you see is real? The search is over. You were with me all the while.” 

Programming note:

Listen live every Monday morning on Monitor Monday when David Glaser reports on “Risky Business,” 10 Eastern and hosted by Chuck Buck.