Help: What Do I Do Now?

The PHE has ended and the three-day SNF rule has returned.

Following up on my previous article posted in April regarding the return of the mandated three-day stay for Medicare patients to discharge to a skilled nursing facility (SNF), now that the federal public health emergency (PHE) has ended, I would like to focus on some of the operational confusion and hurdles I have seen. I would also like to reference that news regarding this topic was released in partnership with the Center for Case Management and my company, Phoenix Medical Management, via social media platforms.

Our companies saw this coming, with full recognition that many case managers left and entered while the PHE was in effect. Many frontline staff had no understanding of “the way we used to do it” before COVID. Thus, what I have seen is lots of questions regarding the counting of medically necessary days, documentation needs, and just the clear miss of the three midnights until the patient is ready to go to an SNF. When this scenario arises and patients lack the appropriate days, it causes confusion and communication issues with the care team and post-acutes.

Okay, so let’s go through the basics: if the patient is initially meeting all requirements for medical necessity, then the continued days of the hospitalization for post-acute care are all medically necessary. There is no need to provide daily clinical reviews using InterQual or MCG on the subsequent days for the three-day stay to qualify for skilled care. 

The recommendation will be to develop a flowsheet that asks the following questions:  

1. Patient SNF appropriate (Y/N)
2. Patient is Medicare (Y/N) If Medicare Advantage (MA), is the three-day stay required (Y/N) – if N, stop
3. Does the patient fall under a Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) program that qualifies for an exception to the three-day stay rule (Y/N) – if Y, stop
4. Did the patient have a previous qualifying inpatient hospitalization within the last 30 days (Y/N) – if Y, stop
5. If patient is inpatient, date/time of order
6. Patient will pass three midnights when ready for discharge (Y/N)
7. Information sent with referral to post-acute care (Y/N)

What the skilled placement facilities will want is verification of the inpatient order so they can guarantee the time requirement for Medicare approval. Failure to have this would jeopardize the SNF having a qualifying stay to guarantee their reimbursement. Also, case management teams will want to make sure they understand their Medicare Advantage contracts to determine if they follow the three-day rule, as many of the MA plans will still authorize patients to transfer to SNF under outpatient with observation services, or under inpatient level of care with a less than three-day stay.

Programming note: Listen to Tiffany Ferguson’s live reports Tuesday on Talk Ten Tuesdays, 10 Eastern, with Chuck Buck and Dr. Erica Remer.