Medicare and Discharge Planning Webinar FAQ

Q: Is it a 3 day, 2 midnight stay or is it 3 midnight stay to qualify for Medicare SNF benefit?

A: It is a consecutive 3 day stay to qualify for Medicare SNF benefit. On a related note: CMS does have a separate rule for physicians commonly referred to as the 2-midnight rule, which relates to observation status. “Under the rules' two-midnight presumption, a physician should order an inpatient admission if the physician expects that the patient's stay in the acute care hospital will be at least two midnights”

Q: Why do hospitals choose to use observation status over inpatient status?

A: Decisions regarding whether to admit someone to the hospital or not are complicated, and often influenced by whether a particular individual’s insurance will cover the stay or not, and under what circumstances. When a hospital chooses whether to admit a Medicare beneficiary as an inpatient (vs. putting them in outpatient or “observation” status), the hospital has to consider Medicare billing rules.  If the hospital puts someone into the ‘wrong’ category (in accordance with Medicare billing guidance), the hospital risks not being paid at all for that patient, or being told that they have to pay back the payment later.  Hospitals are penalized for readmissions, so there is an incentive to put patients on observation status so they are not counted as a readmission should they return. Therefore, hospital staff does their best to try to admit/refuse admission based on Medicare’s rules. Additionally, Medicare is not able to provide exact guidance on every possible situation/diagnosis that a hospital may encounter, so the hospital staff have to try to interpret how a particular billing rule might affect a particular situation.  In August 2013, Medicare instructed hospitals to use “two midnights” as a guideline for considering admission vs. observation status (i.e., if someone is expected to be in the hospital for at least 2 midnights, they should be admitted), but that guidance has led to many additional questions.  Based on a patient’s initial clinical presentation at a hospital, especially to providers that have never seen that patient before, it is challenging to predict whether a patient will need to be there for two midnights or not. Therefore, Medicare has continued to work with hospitals on developing clearer guidance for hospitals regarding when to admit someone as an inpatient and when to put someone in observation status. See this Modern Healthcare Article. 


Q: I've heard lots of criticism about the Medicare website for nursing home ratings - that the information (the 5 star rating, etc.) is outdated and not helpful. Do you find that's true?

A: According to the Medicare website, the nursing home compare data was last updated on February 19, 2015 (this document prepared February 25, 2015). So in that sense it is not very outdated. Data on that site is updated on or about the third Thursday of every month. That being said, data cannot be reflective of a patient’s entire experience, so helpfulness is relative. The nursing home compare tool is one way to get information, but certainly not all encompassing. That is why it is a good idea to visit facilities and ask people about their personal experiences, and seek recommendations from others you may know. It is important to note that the experience a person can also be dependent on staff and staffing levels which can change. Someone who goes to a skilled nursing facility and then returns for care 5 years later may have an entirely different experience because factors have changed. In addition, changes in management and ownership can also impact staffing and care delivery.

Q: How does this [having a different physician at a SNF and in the community] reconcile with a patient's right to select their own physician?

A: The patient absolutely still reserves the right to select their own physician. The patient makes the decision to go to a skilled nursing facility. Just like a hospital, a patient can request a different physician and they have the right to request transfer to a different skilled nursing facility if he or she is unhappy with his/her care. Sometimes primary care physicians do follow patients at nursing homes as they are also nursing home physicians. That is actually a good way to choose nursing homes if someone wishes to have their primary care physician working with them at a skilled nursing facility. Ask your PCP what skilled nursing facilities they follow. A primary care physician cannot provide services to their patients while they are in a hospital or skilled nursing facility because it’s like having too many cooks in the kitchen. Imagine if two different doctors were to prescribe different courses of treatment and medication. It would be poor medical treatment and potentially dangerous for the patient, and it would wreak havoc with health insurance reimbursement, especially if services are duplicative. So, when someone discharges from a SNF, patient information is faxed to the office of the patient’s primary care physician so they can be up to date on the patients treatment and medication needs.

Q: Are there organizations that provide consumer (potential patient) training for planning for these transitions?  Group or individual...

A: This is a fantastic question. As far as I am aware, there are not. However, there are organizations that help people plan for long term care needs. There is a very pervasive statement: “Discharge begins at admission”, which is very true for inpatient staff, but shouldn’t be so true for patients.

Q: When a patient is in a SNF and he needs home health after discharge, should his PCP write the order or the attending physician at the SNF?

A: The attending physician at the SNF would write the order for home health care. A nurse practitioner also has privileges to certify patients for home health through signing a face to face encounter, but cannot order it.

Q: If Consumer does not get SNF Choice #1, and has to go to SNF choice #2 or #3, does the Consumer get to automatically transfer to their choice #1 when a bed opens up there?

A: No.

Q: What are the qualifications needed to be able to sign up for Medicaid in Advance/Before Crisis Mode?  Is there an income requirement?  If so, is there a spend down level and what is the current "Look Back" if pertinent

A: Information on Medicaid eligibility requirements, which varies by person, population, and financial situation. 

There are income requirements for all programs. It will not always be feasible to sign up for Medicaid in advance of a medical emergency. However, for those who have income and categorical eligibility already, it is better not to wait. Depending on someone’s income, they may need to have a spend-down to enter the Medicaid program, which has to make financial sense for that person’s situation. That is a very individualized decision.

When you apply for Medicaid, any gifts or transfers of assets made within five years (60 months) of the date of application are subject to penalties. Any gifts or transfers of assets made greater than 5 years of the date of application are not subject to penalties.“ This article from Forbes explains this nicely.

Q: If Stephen had Medicaid {from the case example} instead of Medicaid pending, would this have helped him get into a better NH?

A: That is possible, though “better” is up to individual interpretation. It would be easier to find long term care facility that will accept him if he has a payer source. “Medicaid Pending” can also be thought of as Medicaid nothing. This person doesn’t have insurance. In all other realms of medical care, finding a physician, or a nurse, or anyone who will provide services to someone who cannot pay and does not have insurance is much harder than it would be for someone is insured. The same can be said about long term care facilities. If a long term care facility accepts Stephen, they are taking a risk. It would be difficult to discharge him to another facility or to home, and there is no guarantee that they will be reimbursed for the care that they provide, or even that the family will effectively complete the application. Generally, long term care facilities that are able to accept “Medicaid pending” are ones that are having trouble filling beds, which means that they are not in demand by patients.

Q: What insurance should the individual purchase for custodial care while on Medicare?

A: It depends on the individual circumstance. For some it may make sense to purchase a long term care policy. We are unable to make recommendations on whether people should or shouldn’t purchase one of these policies. A financial planner may be able to help. Some people may spend-down all of their assets to get coverage through Medicaid for custodial care. Others will save money to pay for caregivers, and some will have family members or friends that provide custodial care.

Q: Is there any insurance (other than LTC insurance) that would more hours of home care than the CCP waiver max of 25 per week?  What if a client needs a lot more to be safe at home and avoid SNF placement?

A: There is not any insurance other than long term care insurance that would provide more hours of home care than the CCP waiver max of 25 per week that I am aware of. This is when social support and creativity become very important. People can hire friends or family members to be caregivers through this program. So, if a family member or friend was going to provide these services regardless, they can be reimbursed for up to the CCP waiver max. RIC has some tips on how to do this. 

Q: Can you speak to medication management and administration when a person discharges home?  What are the best practices to make sure there is med reconciliation and compliance; they are refilled correctly, etc?

A: Depending on the facility, patients will discharge home with the remaining supply of medication from the skilled nursing facility. Discharge instructions speak to medications. Knowing their patients, and the support they have, if someone is generally non-compliant or has limited understanding of their meds, a nurse will have a patient’s family member or representative present so that both the patient and another person hear and read instructions. Many nurses use a “teach back” method to confirm the patient understands how to manage medications properly. Also, in my experience medication lists are faxed to both the primary care physician and the patient’s choice pharmacy from a SNF and provided to the patient as part of discharge paperwork. Regarding compliance, depending on a patient’s needs and wants, there are pharmacies that will do home delivery, some that will provide medications in packages by time of day. Anecdotally, many of my former clients that were successful in med management used a pill box, set phone alarm reminders, or had a spouse that assisted in med management. There are also a variety of smart-phone apps. A pharmacist also may have valuable recommendations in this area.

There is plenty of literature on best practices for medication reconciliation.

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