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Why NACs Need to Actively Manage Physician Certs/Recerts—and What to Look for

The nurse assessment coordinator (NAC) who also serves as the primary Medicare nurse doesn’t always complete either the physician certification/recertification process or the beneficiary notification process for Medicare residents, says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director of clinical reimbursement for LeaderStat in Powell, OH. Heichel will present the April 12 session “Understanding the Process for Beneficiary Notices and Physician Certifications” at the AAPACN 2024 Conference, which will take place April 10 – 13 in Hollywood, FL.

“However, the NAC is the gatekeeper of the many different facility processes that fall under the umbrella of skilled services,” stresses Heichel. “You are the manager—whether or not you are the person directly completing the task. For example, you monitor that daily documentation to support skilled services is in the medical record, you monitor the interdisciplinary team’s participation in the MDS process for timeliness and accuracy, and you monitor the accuracy of Medicare claims as part of the triple-check process.”

That same need for oversight applies to physician certifications/recertifications and beneficiary notifications, says Heichel. “As the lead for skilled coverage, you need to know enough about these processes—and be engaged enough with these processes—to ensure that all the pieces are in place, and your skilled nursing facility (SNF) is in compliance. There can be significant financial penalties associated with these processes. For example, a missing component on a physician certification/recertification could bring into question the entire claim. So, you want to be in compliance 100 percent of the time.”

The NAC has numerous opportunities to audit both processes, suggests Heichel. “During my conference session, for example, we will discuss using the weekly Medicare meeting and the monthly triple-check process to ask the right questions and ensure that these processes are being done timely and accurately even when you aren’t directly completing them.”

Common mistakes with the physician certifications/recertifications that are required for all fee-for-service Medicare Part A residents include the following, according to Heichel:

Initial certification date equals the admission date too consistently

Many providers believe that the physician (or physician extender) must sign and date the initial physician certification on the day of the resident’s admission, says Heichel. “However, it could be a red flag to an auditor if the admission date and the date on the initial physician certification always match. You have to navigate a lot of variables in nursing homes. Very little happens in a certain way all the time, so documentation that shows a pattern of always events—like the initial certification date and the admission date always matching—suggests that something is wrong.”

For example, a resident may be admitted after 8 p.m. on a Friday night or late on a Saturday afternoon, points out Heichel. “In these types of scenarios, it is unlikely that a physician would be available to sign the initial certification on the admission date. So, an auditor may suspect that the SNF gets physicians to backdate when the initial certification is always dated the same day as the admission date. For example, if the resident was admitted on Feb. 26 and the physician came in on Feb. 29, the facility asked the physician to date the initial certification Feb. 26.”

That’s not consistent with Medicare requirements, stresses Heichel. “The physician needs to date the initial certification with the date the pen hits the paper. The physician dating that certification with a day that they aren’t actually signing it calls into question the integrity of the rest of the information on that certification, as well as the recertifications. If you are willing to make that leap at the very beginning of the resident’s stay, the auditor will have concerns about your willingness to cut corners with other Medicare requirements related to the resident’s skilled stay.”

Heichel points providers to two key sources of information about when the initial certification must be signed:

* The Medicare General Information, Eligibility, and Entitlement Manual. “The federal guidance on the initial physician certification timing requirements that covers all SNFs is found in section 40.2, Certification for Extended-Care Services, in chapter 4, “Physician Certification and Recertification of Services,” of the Medicare General Information, Eligibility, and Entitlement Manual,” says Heichel. “The key statement is that ‘certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable.’”

So, the Centers for Medicare & Medicaid Services (CMS) does not say that the initial physician certification date must be the same as the admission date, explains Heichel. “CMS gives providers some leeway—some wiggle room—with the phrase ‘or as soon thereafter as is reasonable and practicable.’ For example, I would interpret that to mean that if a resident is admitted at 8:00 p.m. on a Friday night, you can get that initial physician certification signed when the physician comes in on Monday morning, and you will be within the intent of chapter 4.”

Note: Learn details about physician signature requirements (e.g., handwritten signatures, electronic signatures, etc.) in section, Signature Requirements, in chapter 3, “Verifying Potential Errors and Taking Corrective Actions,” of the Medicare Program Integrity Manual.

* The Medicare administrative contractors (MACs). “On top of the federal rules, you also have to be concerned about the MACs that actually pay the fee-for-service Part A bills,” says Heichel. “They each could have their own more stringent rules as to how they interpret what is a timely initial certification. For example, a MAC may decide that ‘as soon thereafter as is reasonable and practicable’ means no more than 48 hours after admission.”

Providers should contact their MAC’s medical review department to find out how that specific MAC applies the federal timeliness requirement for the initial certification, suggests Heichel. “Then, you want to follow whichever rule is more stringent, whether that is the MAC’s interpretation or the Medicare General Information, Eligibility, and Entitlement Manual guidance.”

For example, if the MAC has a 48-hour time limit for doing the initial certification and that resident comes in at 8 p.m. on a Friday night, the interdisciplinary team needs to have a process in place to get that initial certification completed by 8 p.m. on Sunday night, explains Heichel. “Following the MAC’s more stringent requirement in this case safeguards you in case of medical review—and ensures that you have met the less stringent federal requirement as well.”

Missing components on physician certification/recertification forms

The Medicare General Information, Eligibility, and Entitlement Manual specifies that there is no form requirement for physician certifications/recertifications, says Heichel. The following excerpt from section 40, Certification and Recertification by Physicians for Extended-Care Services, in chapter 4 explains:

Payment for covered posthospital extended care services may be made only if a physician (or, as discussed in §40.1 of this chapter, a physician extender) makes the required certification and, where services are furnished over a period of time, the required recertification regarding the services furnished.  

The skilled nursing facility is responsible for obtaining the required certification and recertification statements and for retaining them in file for verifications, if needed, by the A/B MAC (A). The skilled nursing facility determines the method by which the certification and recertification statements are to be obtained. There is no requirement that a specific procedure or specific forms be used, as long as the approach adopted by the facility permits a verification to be made that the certification and recertification requirements are in fact met. Certification and recertification statements may be entered on or included in forms, NOTEs, or other records that would normally be signed in caring for a patient, or a separate form may be used. Except as otherwise specified, each certification and recertification statement is to be separately signed. See Pub. 100-08, Medicare Program Integrity Manual, chapter 6, section 6.3 regarding medical review of certification and recertification in SNFs.

“So, CMS doesn’t care what a certification/recertification looks like,” explains Heichel. “As long as the physician is signing for the correct components, the certification/recertification can be paper or electronic. And, you can write a tight narrative note, use a form developed in-house, or purchase a form from a supplier.”

Most providers use a variation of the same form, notes Heichel. “In audits that I have completed, forms usually have a section for the initial certification and then a section for each recertification. Within each section, there are lines and boxes for the resident-specific information to be entered. The intent is for facility staff to complete each section as needed so that you have all the required components from the Medicare General Information, Eligibility, and Entitlement Manual. Then, the physician signs and dates that section, and you are in compliance.”

While that seems simple, the reality is that information is often missing on certifications/recertifications, says Heichel. Common missing components include the following:

* The resident’s daily skilled need (or continued daily skilled need for recertifications). “This is typically a narrative box where you describe the skilled need that justifies the resident’s skilled stay,” says Heichel. “We will review in more detail what may count as the daily skilled need during my presentation.”

At some point in the resident’s stay, the daily skilled need could change, notes Heichel. “For example, initially the resident’s stay may be for a condition that they received treatment during their qualifying hospital stay. Then later during the stay, that condition may have resolved, but they are skilled for an issue that crept up during the SNF stay. That switch needs to be reflected on the resident’s recertifications.”

* The estimated period of continuous SNF care. “For each recertification, the interdisciplinary team must determine, ‘How much longer do we think that this resident will need a skilled level of care?’” says Heichel. “For example, does the team expect them to be skilled for 10 more days or four more weeks? Whatever the time period is, your team gets to determine that.”

The first recertification needs to be done by day 14 of the resident’s stay, and every subsequent certification covers a maximum of 30 days, says Heichel. “The team must provide an updated estimate for each recertification period.”

* The post-SNF plan. “Recertifications also should provide general information about the discharge that will occur after Medicare ends,” says Heichel. “For example, will the resident stay in the nursing home long-term? Will they go to assisted living? Will they go home to independent living with or without home health services? The post-SNF plan can change from one recertification period to the next, and you should describe the most current plan on each recertification.”

When the physician has signed and dated a certification/recertification with one or more blank components, that is a concern, says Heichel. “It raises questions about the timing of those physician signatures. Are they just signing everything that is put in front of them? What does your process to ensure compliance look like?”

Questionable recertification dating practices

There are two common problems with recertification signatures and dates, says Heichel. These are as follows:

* Late recertifications. “All certifications/recertifications have to be signed according to the timetable laid out in the Medicare General Information, Eligibility, and Entitlement Manual,” says Heichel. “If the physician signs and dates the recertification after the end of the recertification period, then you are late.”

CMS acknowledges that isolated late certifications/recertifications may occur, says Heichel. “However, in audits, I most often find late recertifications with no evidence of a delayed recertification statement—which is a requirement under section 40.5, Delayed Certifications and Recertifications for Extended-Care Services, in chapter 4 of the manual. There must be a delayed certification/recertification statement in place explaining why the delay occurred.”

For example, a staff member miscounted the days in the recertification period because they didn’t look at the calendar correctly to account for a 31-day month, says Heichel. “As a result, they told the physician to sign the recertification on a date beyond the 30-day maximum. In that scenario, you would need to create a delayed recertification statement when you discovered the error.”

* Prefilled recertifications. “Sometimes in audits, a facility’s certification/recertification form will have all the recertification physician signatures and dates already completed when the resident hasn’t even reached those points in time during their stay,” says Heichel. “In this situation, staff are trying to get ahead by having the physician sign and date two or three of the recertifications, without providing any information for the physician to review, so that the recertifications are in place if they are needed.”

However, the physician should never sign blank documents, stresses Heichel. “And, it’s really difficult for the physician to agree that a resident should continue to be skilled, for example, 50 days into the future. The process should be: You complete the appropriate portion of the form as a team and present it to the physician. Then the physician reviews it and, if they agree, signs and dates it. Then, you move on to the next recertification.”

Other issues that Heichel plans to cover during his session include understanding how to rank the importance of accurate, timely certifications/recertifications. “We’ll look at the weight these carry in a Medicare audit situation and how much payment is actually at risk,” he explains.

In addition, Heichel will address key process questions. “We will discuss the variety of disciplines that are assigned to run the certification/recertification process in a SNF and consider which discipline is the most ideal and which should be used with caution. This is certainly much more than a clerical process, and you need to be sure that the person completing certifications/recertifications has the knowledge to do that.”

Beneficiary notices: Another technical requirement

Last but not least, Heichel’s presentation will address beneficiary notices: the financial liability notice process (e.g., the Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN)) and the expedited determination process (i.e., the Notice of Medicare Noncoverage (NOMNC) and the Detailed Explanation of Noncoverage (DENC)). “Like physician certifications/recertifications, these notices are a technical requirement of Medicare,” he notes. “If the interdisciplinary team makes certain determinations on skilled coverage, you have to issue the correct notices to those residents. It may be a financial liability notice, it may be an expedited determination notice, or it may be both.”

The forms used in these processes are very specific, says Heichel. “In audits, I often find that providers are using outdated forms, or the forms have been modified to the point that they are no longer valid. So, we will be discussing what counts as a correct form, which scenario requires which form or forms, and the timing requirements for each form—and what applies to Part A vs. Part B.”

In addition, it’s important to talk about the post-notice process, says Heichel. “For example, how does your facility respond when they receive appeal notifications from your Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO)? There is a timeline that you must follow, and if you miss providing the requested information by the deadline, the resident wins that round of the appeal. So, you need to understand the different situations and the timelines that go with them to ensure that your team has the opportunity to respond appropriately.”

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