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A Beginner’s Guide to Medicare Expedited Determination Notices

Polaris Group Profile
Polaris Group
December 20, 2021
January 21, 2022
Polaris Group Profile
Polaris Group
January 21, 2022
Summary

As Medicare audits return, it’s important to understand when and how to share a Medicare expedited determination with your patients.

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As Medicare audits return to pre-COVID levels, it’s important that facilities understand when and how to share a Medicare expedited determination with their patients.

What is a Medicare Expedited Determination?

According to the Medicare Claims Processing Manual, Chapter 30 Financial Liability Protections the Financial Liability Protections (FLP) Provisions of Title XVIII of the Social Security Act protects beneficiaries, healthcare entities and suppliers under certain circumstances from unexpected liability charges. Skilled Nursing Facilities (SNFs) have specific notices that are required when an enrollee’s Medicare coverage does not authorize a course of treatment or when a beneficiary is no longer at a skilled level of care.

Risks of Not Giving Medicare Denial Notices

Providing the wrong Medicare expedited determination notice or not providing a notice at all puts your facility at risk in a few ways:

  • Your expedited determination notice procedure is part of your Medicare audit. If you perform poorly on your audit, it can affect your facility’s reimbursement and certification.
  • If a valid notice is not provided within the specified timeframe, the facility will be held in “provider liability status”. That means the facility is responsible for all costs during the specified timeframe and you cannot bill any payer or beneficiary which negatively impacts your facility finances.

To prevent these challenges, it’s important to understand which notice is provided and in what situation the facility should provide the notice.

The Four Types of Medicare Denial Notices and When to Share Them

The Center for Medicare Services (CMS) has four different types of valid notices:

#1 The Notice of Medicare Non-Coverage (NOMNC/Generic Notice)

What is it?

The Notice of Medicare Non-Coverage (NOMC) notifies patients of their right to appeal being discharged off Medicare Part A, Part B, or Part C (Managed Care).

When should you share it?

The NOMNC/Generic Notice should be provided no later than two days prior to the last covered day. CMS defines “two-days” as calendar days, not 48 hours’ notice. A facility can provide the notice at 8am or 5pm, if it’s within two days of the last covered day. The signature of the dated notice by the beneficiary and/or legal representative identifies the beginning of that timeframe.

#2 The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)

What is it?

This notice informs beneficiaries that an upcoming service or item is not eligible for Medicare coverage. If the beneficiary proceeds with the item or service and submits it for Medicare payment, the submission will be denied.

When should you share it?

The SNFABN should be provided prior to services that Medicare may not pay for.

#3 The Advanced Beneficiary Notice (ABN)

This notice serves the same purpose and has the same issuing parameters as the Skilled Nursing Facility Advanced Beneficiary Notice. It applies to Medicare Part B non-covered related services and items.

#4 Detailed Explanation of Non-Coverage

What is it?

The DENC is a document that facilities provide to the Center for Medicare Services Quality Improvement Organization (QIO). It includes a detailed explanation of why a patient’s services are no longer necessary and do not need to be covered. This form identifies facts specific to the beneficiary’s discharge and the provider’s determination that coverage should end.

When should you share it?

The DENC is completed when a beneficiary appeals the facility’s decision to discontinue Medicare Part A and should be completed the day the facility is notified by the QIO of the appeal.

All these CMS forms must be the most recent CMS forms which is identified by their approval date, or it is not a valid form. You can visit CMS Notices & Forms for the most recent forms.

Medicare Denial Notices Protect Beneficiaries and Facility from Financial Liability

Medicare audits can be stressful, but Medicare denial notices are one area where you have complete control. The first area an auditor reviews is whether your notices are timely and valid, so understanding when to give the proper notice is paramount to a facility’s financial health.

With a little training and process work, issuing denial notices can be an easy and streamlined piece of your back-office and patient relations work.

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