Administrative Presumption of Coverage

Overview

This presentation gives a comprehensive overview of Administrative Presumption of Medicare Coverage, which is not well understood. It is important to know each resident’s payer on admission. Administrative Presumption of Coverage after a 3-day Qualifying Hospital Stay (QHS) will provide Medicare coverage through the Assessment Reference Date of the 5-day PPS MDSs for residents who will be correctly placed into one of the specific case mix groups that have been identified by CMS to qualify for Presumption of Coverage. The SNF ABN 10055 must be presented to residents/representatives. This presentation will report the requirements for discharge directly to the SNF after a 3-day Qualifying Hospital Stay. The MDS Assessment Reference Date requirements and the specific qualifiers for each of the nursing, PT/OT, SLP and NTA case mix groups that qualify for Administrative Presumption of Coverage will be reviewed.

Instructor

Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC

Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter & Co. P.C., providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

• 1.5 hours for Licensed Nurses
• 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on November 11, 2024.