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Reader Questions

Published on Sun Jan 16, 2005

Don't Be Too Early Or Late With Noncoverage Notices

Question: Is there is a certain period of time that a SNF has to notify a Part A-stay resident in the facility that Medicare fee-for-service will no longer cover his stay in the nursing home?


- Iowa subscriber


Answer: If the resident is already on Medicare, the facility must provide the decertification notice no later than the last day of coverage.

If you give notice further in advance, the fiscal intermediary may question how you knew that on a future date the resident would no longer require Medicare coverage.

Source: Marilyn Mines, RN, BC FR&R Healthcare Consulting Deerfield, IL

Editor's Note: For more information on notice of noncoverage for SNFs, go to www.cms.hhsgov/medicare/brni.

Beware Discharge For Wound Payment-Related Issue

Question: My facility has admitted a SNF Part A-stay resident who requires a wound vac to treat a serious ulcer. The discharge planner at the hospital did not tell us that the resident required this treatment, and Medicare doesn't pay anything extra for it compared to routine wound treatments captured on the MDS.

May we discharge the resident as an alternative to providing the wound vac, if the attending physician insists on this treatment?


- Georgia subscriber


Answer: No. The Code of Federal Regulations governs the transfer and discharge of residents, and it states that the facility must permit each resident to remain in the facility and not transfer or discharge the person unless:

  •  The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;

  •  The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;

  •  The safety of individuals in the facility is endangered;


  •  The health of individuals in the facility would otherwise be endangered;

  •  The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or

  • The facility ceases to operate.

    A court would likely conclude that the facility can meet the resident's needs (for the wound treatment). The real issue is payment, not level of care.

    Any sister facilities in the community would unlikely to be willing to accept the transfer because the wound vac is not reimbursable as an additional therapy. For these reasons, transfer or discharge does not seem like a good option.

    Moreover, a facility may only transfer or discharge a patient when it is safe to do so. And transferring the resident to another nursing home that doesn't provide the wound vac (if the physician insists it's medically necessary) might not qualify (in surveyors' minds) as being safe.

    Source: Christopher Lucas, JD, Mechanicsburg, PA

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