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| Clinical Coverage Criteria |
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Is home dialysis covered under Medicare/Medicare Preferred? |
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A patient is eligible for home dialysis if the patient and/or family member attends a Medicare approved training program to learn how to administer dialysis, care of the equipment and supplies. This program is 5 days a week and lasts for 10 weeks. When a patient is unable the family member must be present to administer the dialysis.
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Is a slide board for transfer covered under Medicare Preferred? |
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Yes, as a piece of Durable Medical Equipment. |
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Who pays for donor services for a transplant patient? |
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The recipient's insurance. |
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When a patient accesses the Veterans Administration for admission does a denial letter need to be generated? |
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Yes, once you become aware of the admission a denial letter may be issued to the patient since the VA will attempt to bill Medicare Preferred.
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How many days does a Medicare Preferred patient receive for inpatient skilled nursing? |
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A Medicare Preferred patient receives 100 skilled nursing facility days per “episode of illness”. An episode of illness is defined as the first day the patient is admitted to a facility until such time as all skilled needs are met and the patient either returns home or becomes custodial level of care.
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A patient may or may not use the 100 days consecutively.
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If the patient does NOT use all of the days and is discharged home or to custodial level of care, but has another admission to an acute or skilled nursing facility within 60 days of discharge, that is considered a continuation of the episode of illness. These days would be counted as a continuation of the episode of illness.
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If the patient does NOT use all of the 100 days and is discharged to home or custodial level of care, but has another admission to acute or SNF on day 61 the patient is entitled to another 100 days of skilled nursing facility care.
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If the patient is at a skilled level of care after using the entire 100 days consecutively and remains in the SNF, he/she will be considered to have used a onetime lifetime benefit of 100 skilled nursing facility days. Most patients in this situation become long-term nursing home patients and either self pay or apply for state Medicaid assistance.
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An example of this type of patient would be a patient with a g-tube which is the only method of nourishment.
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Another example is an insulin dependent patient who cannot self-administer insulin.
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Because this patient will remained skilled for the rest of his/her life, there will never be a time they are unskilled for the required 60 day period, thus will not receive another 100 days.
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How many grace days should be given when a termination of benefits letter is written on a skilled nursing facility patient?
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At least one day prior to termination. The date of the letter must be either prior to or the same date that the letter is delivered to the patient.
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When a patient elects hospice and then is admitted urgently to the hospital, can hospice dis-enroll the patient?
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Yes, if the hospice agency and the hospital the patient is admitted to do not have a contract for inpatient hospice, the patient can be dis-enrolled from hospice.
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If a patient is admitted with an old workmen's comp injury should a coordination of benefit be filed?
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Yes, even if the case had been closed if the injury is related to the initial case, it will be reopened. |
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