CMS Says Post-Acute Care Choice Only Goes So Far

CMS Says Post-Acute Care Choice Only Goes So Far

Access to post-acute care remains an issue in most hospitals around the country. Exacerbated by the staffing challenges that worsened during COVID-19, the ability to get a patient transferred to a skilled nursing facility (SNF) in a timely manner is rare.

That creates several issues.

First, it delays the patient’s recovery. While hospitals strive to provide therapy services to all eligible hospitalized patients, patients awaiting transfer to an SNF are often bypassed when there are other patients needing an initial therapy evaluation or patients returning from surgery who need to be assessed for ambulation abilities.

That patient also occupies a bed that may be needed by a patient in the emergency department, if the census is high. Holding an inpatient in the ED in a bed in the hallway because a patient upstairs is stuck in the hospital awaiting an SNF bed creates a quality-of-care issue, staffing problems, and poorer outcomes. And of course, the hospital is providing additional care without any additional reimbursement.

Also exacerbating the issue has been a provision in the update to the discharge planning conditions of participation (CoP) adopted in 2019. In this update, the Centers for Medicare & Medicaid Services (CMS) has stressed increased patient choice and honoring their goals of care. But as I have discussed in the past, it also brought up many unknowns. But now I can report on one very big clarification from CMS. First, let me say that this update is from personal correspondence with a CMS staffer and not official guidance.

With that, this clarification addresses patient choice.

If you read the Federal Register, it seems to suggest that CMS wants patients to be offered the choice of any post-acute provider in their desired area that could provide the care needed for the patient. So, for example, if a patient on dialysis required care at an SNF, the patient’s choice would be limited to facilities that provide dialysis. However the vast majority of patients needing SNF care do not have specialized needs, and just about all SNFs can meet their care needs. And I am sure you will agree that every patient wants a 5-star luxury SNF with private rooms good staffing and great food.

But most 5-star facilities do not have open beds when you need them. So the question was – when offering the patient a list of facilities, must you include the facilities that can meet their needs, but do not have an open bed? Since CMS provided no specific guidance, most chose the conservative approach and included those facilities without open beds on their lists.

But now I can report that the answer from CMS is no. The list you provide the patient only has to include facilities that can meet their medical needs and have an available bed. Whew!

I am not at liberty to reveal my CMS contact, but if you go to and scroll to the bottom, you can see the email I received.

It is important to note that the list you provide your patients is not limited simply to those with an open bed and the ability to provide their needed care. You can, and probably should, also indicate which facilities accept their insurance, although I will note that the CoPs state that it is the patient’s responsibility to determine which facilities are in their network.

You must also include at a minimum the most recent quality and resource use data from CMS Care Compare, but you can supplement that information. For example, you are free to indicate which may be part of your accountable care organization (ACO) or participate in any applicable bundled payment programs, and if you have robust data, you can include measures such as the SNF’s readmission rates or outcomes data for specific diseases.

What does this mean? If you have a standard printed list of nursing homes and home care agencies you provide to every patient that lists all the post-acute providers in the area, and you instruct the patient to go to the CMS Care Compare webpage to get quality and resource data, it is time to get into the 21st century. You need a product like Strata Health that can create custom lists that include only facilities with open beds, can indicate which insurances they accept, and can provide updated quality measures. You know that if the patient sees the name of the 5-star facility on the list but then is told that the facility is full, they are going to want to wait around a few days until a bed opens up. Heck, I think I would, if I was in that position, especially if I think there are no consequences to me.

But what if the patient balks at being sent to a facility with two stars if it is the only one with an open bed? If there is an open bed at a facility and the patient refuses it, you can start to charge the patient to stay and wait.

It is CMS’s opinion that if a facility is licensed and allowed to accept Medicare patients, the facility is capable of safely providing the necessary care and that although a higher-star-rated facility may be desirable, it is not a patient’s right to stay in the hospital without any obligations awaiting another facility.

Be sure the follow-up Important Message from Medicare (IMM) has been given and let the patient appeal their discharge, which will provide some “free” days, and if they don’t appeal, give the Hospital-Issued Notice of Non-Coverage (HINN) that day, at which point their financial liability begins at midnight.

When the Quality Improvement Organization (QIO) sees that you have a safe discharge plan for the patient and an accepting, Medicare-certified SNF, they will rule in your favor. Some hospitals may be hesitant to do this, fearing repercussions in patient satisfaction, but remember the patient in the hallway bed in the ED whose health is being compromised.

Hopefully, this information will be of use to you. We all want what is best for all patients. Sometimes that includes doing what is necessary, but perhaps not optimal.

Print Friendly, PDF & Email

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Remain Compliant – and Take the Money

Remain Compliant – and Take the Money

Our first topic today is local coverage determinations (LCDs) and variation. I have written in the past about national and local coverage determinations, and I

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →