The Public Health Emergency Renewal of January 11, 2023: What is the Impact on Skilled Nursing Facilities?

The U.S. Department of Health and Human Services (HHS) announced the twelfth extension of the Public Health Emergency (PHE) on January 11, 2023. With each PHE extension, several flexibilities and waivers remain in effect. One that has the greatest impact on skilled nursing facilities (SNFs) is the 3-day prior hospitalization requirement for Medicare beneficiaries.

Although the 3-day prior hospitalization for Medicare Part A coverage in a SNF continues to be waived, providers must be aware that the medical record must contain documentation to justify the medical necessity for the patient’s clinical needs for SNF admission as outlined in the Medicare Benefit Policy Manual, Chapter 8, Section 30.

One of the external contractors for the Centers for Medicare & Medicaid Services (CMS) is the Supplemental Medical Review Contractor (SMRC). SMRCs are responsible for conducting reviews and focusing on a specific area identified by CMS.

Noridian Healthcare Solutions, LLC (Noridian) is one of the SMRCs for CMS. Noridian has been tasked to do post-payment audits focusing on Medicare Part A SNF claims without the 3-day prior hospitalization from March 1, 2020, to December 31, 2021.

If the SNF receives an Additional Documentation Request (ADR) letter that has the 3-Day Rule Waiver PHE identified as the focus for review, it is important to be aware that the review will not be limited to the use of the waiver. Based on the listed documentation requirements, Noridian audits the medical record for the entire Medicare Part A stay. For more information, you can review the Noridian Documentation Requirements.

Even when the directive is to review claims up to December 31, 2021, there is a possibility that CMS may extend the claims focus audit period. The PHE does not change the Medicare Part A documentation requirement. Documenting that the “Medicare Part A coverage is covered under the COVID-19 Waiver” was and will not support the reason for skilled coverage without the 3-day prior hospitalization. Regardless of whether the PHE is in effect, the medical record must have the documentation for reasonable and medically necessary services.