Please help! Medicare Part A SNF facility coverage after hosp for long term care patient

[Anonymous]

Anonymous wrote:I wonder if the COVID SNF stay/payments were under the waiver but then maybe additional paperwork wasn't done to continue the new benefit period: https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-Preparedness/Documents/COVID19/3-Day%20Waiver%20FAQ.pdf

Speculation and I didn't fully read to know how it all works, but perhaps looking into because I don't think the original benefit period ends based on 60 days without Medicare payment. It ends based on level of care, and if he's been private paying for skilled nursing then he still was at SNF level of care (if I'm following the timeline correctly in that he never left that level of care).

Also the PHE was renewed (to address the part about at least through April 21 on my first link): https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx

I think your best bet would be get documentation of why he needed the SNF new benefit period for COVID and why he needed that to continue for 100 days and ignore that subsequent hospitalization because he appears to have started a new benefit period when they started billing for the COVID.

I know you said ignore Tricare, but I thought Tricare was supposed to pay as long as medically necessary. So for me that angle would be that if Tricare wasn't paying, it wasn't medically necessary for him to be at SNF level of care past September, which would then mean there really was a >60 day break by February, allowing a new benefit period to start for the COVID regardless of the waiver I mentioned above.

Or else I would think Tricare should have still been paying....

[Anonymous]

Wow 20:11 - I think you're right about Tricare. The facility told us that Tricare was especially strict in covering skilled nursing and would only do so for IV antibiotics, daily therapies, or stage 3+ wounds, and that continued progress in PT/OT was necessary for daily therapy, so we didn't ask for more after September.
But the Tricare website says they follow Medicare Part A rule in determining eligibility after Medicare is exhausted. They probably should have been paying all along since progress isn't required under Medicare.
What fools we were to listen to the facility. I think the facility people are not bad people, but what they say sure doesn't match the rules I can find.
I would assume it's way too late now to argue Tricare should have been paying between last September and now.

[Anonymous]

Anonymous wrote:Wow 20:11 - I think you're right about Tricare. The facility told us that Tricare was especially strict in covering skilled nursing and would only do so for IV antibiotics, daily therapies, or stage 3+ wounds, and that continued progress in PT/OT was necessary for daily therapy, so we didn't ask for more after September.
But the Tricare website says they follow Medicare Part A rule in determining eligibility after Medicare is exhausted. They probably should have been paying all along since progress isn't required under Medicare.
What fools we were to listen to the facility. I think the facility people are not bad people, but what they say sure doesn't match the rules I can find.
I would assume it's way too late now to argue Tricare should have been paying between last September and now.

To be clear, I know a fair amount about how Medicare is supposed to work, nothing about Tricare except what I googled, and have no experience dealing with claims for either one. I don't know for sure what should be covered. I'm suggesting how I would handle it because the stories you have been given do not appear consistent.

I do have a bunch of personal experience fighting claims for family members with commercial insurance. We've had issues on one side or the other (provider and/or insurance) for at least 50+% of providers. You name it, I've seen it - denials claiming no prior authorization when I had the letter, telling me reasons for denials that didn't have any relationship to what the EOB actually said, not submitting claims that were supposed to be covered because the provider said that service is never covered (but turned out to be when I made them submit), network issues, multiple other errors.

I would keep fighting until you get all the pieces of the story to line up and make sense. Recently, I finally got insurance to pay for something that should have been covered per their website after getting six different wrong reasons for denial.

If Tricare really should have been paying, the facility should be able to submit the appropriate information. I absolutely would not take their word for it until you see that they have submitted the claim with the actual services he received. I would assume they would have a year to submit but I didn't try to look that up. I basically just bother people until they are sick of me.