Q: Can the 3-Day Qualifying Hospital Stay waiver be used more than once for the same person?

A: The Qualifying Hospital Stay waiver can be used multiple times for the same beneficiary if the following is true:

The beneficiary has had a 60-day break since the last day requiring skilled care. Once the beneficiary has a 60-day “wellness period,” she is eligible under a new benefit period.

With that in mind, remember that other existing Medicare requirements for SNF coverage are not changed by the waiver. You need specific documentation on a case-by-case basis that clearly indicates how the decision for use of the waiver is directly related to the ongoing Public Health Emergency, in addition to continuing to focus on the individual’s skilled need and medical necessity requirements.

Also consider whether the skilling condition would have required an inpatient hospital stay in the absence of the pandemic.

As expected, recent medical review activity has included a close look at waiver use. Notably, Supplemental Medical Review Contractor (SMRC) Noridian reports in their current project that data analysis done by CMS and the SMRC identified a potential area of vulnerability, and the SMRC is tasked to perform medical review on SNF claims (3/1/2020 – 12/31/2021) that had zero hospital days prior to admission.

To avoid potential denials, the IDT should determine and document:

  • What the skilled service(s) is/are,
  • How SNF level of care is met,
  • How the skilled stay relates to the PHE,
  • If an inpatient hospital stay would have likely been necessary to manage the condition(s) in absence of the pandemic (QHS Waiver)
  • Whether the PHE prevented the beneficiary from beginning/completing the 60-day break (Benefit Period Waiver).

From the September 2022 Issue of McKnight's Long-Term Care News