Recovering from an illness or injury often involves care at multiple facilities after an initial hospitalization. If you or a loved one has received post-acute services like inpatient rehab, skilled nursing, or long-term acute care, you may find the billing process confusing. This guide will help you understand common billing scenarios, who pays for post-acute care, and how to manage the paperwork.
What is Post-Acute Care?
Post-acute care refers to medical services needed after a hospital stay to help continue recovering. The main types of post-acute care include:
- Skilled nursing facilities (SNF) for nursing care, therapy
- Inpatient rehab facilities (IRF) for intensive therapy
- Home health for intermittent nursing and therapy
- Long-term care hospitals (LTCH) for complex medical needs
These services aim to help patients regain independence after illness/injury. Medicare covers post-acute care that is considered medically necessary after hospitalization.
Typical Billing and Payment for Post-Acute Care
If you have original Medicare here is the typical billing process
- Medicare pays the post-acute provider a bundled rate per day/episode. This covers most services.
- You pay a daily copay for SNF, IRF, LTCH services that applies to the first 100 days.
- The provider bills you for any copays you owe. You won’t get individual bills for each service.
- You’ll receive a Medicare Summary Notice showing charges submitted and payments made.
- The provider cannot charge more than the Medicare copay amount.
If you have a Medicare Advantage plan, work with them to understand the network, copays, and prior authorization requirements for post-acute care. Give your insurance details to the post-acute provider upfront.
Common Billing Issues to Watch For
Here are some frequent billing problems and how to address them
-
Being billed above the Medicare copay amount Request an itemized bill and ask them to resubmit the claim to Medicare if needed,
-
Getting balance bills after Medicare payment: Post-acute providers cannot balance bill Original Medicare beneficiaries. Ask them to adjust or void such bills.
-
Non-covered services billed: If Medicare denies coverage for certain services, you may need to appeal and provide documentation to support medical necessity.
-
Home health care ending abruptly: Home health agencies must give 48 hours written notice before discontinuing care. Discuss ongoing needs with your doctor.
-
Denied claims: Follow instructions on any denial notices closely. Appeal quickly with medical records to support the services.
Creating a Process to Manage Medical Bills
With some organization, you can minimize frustration and handle post-acute care bills more smoothly:
-
Note important dates like appeal deadlines on a calendar.
-
Create filing systems to store billing paperwork chronologically.
-
Log billing discussions and next steps in a dedicated notebook.
-
Contact providers right away if you receive unclear or questionable bills.
-
Carefully read notices from Medicare and your insurer about coverage.
-
Ask a family member or professional for help if the paperwork becomes overwhelming.
Who Pays for Post-Acute Care?
If you have original Medicare, here is how much you will typically pay for post-acute care services:
Skilled Nursing Facility:
- Days 1-20: $0 copay, Medicare covers 100%
- Days 21-100: $194.50 daily copay in 2023
- After day 100: You pay full cost unless secondary insurance covers
Inpatient Rehab:
- Days 1-90: $203 daily copay in 2023
- After day 90: You pay full cost unless secondary insurance covers
Home Health:
- All visits: $0 copay, Medicare covers 100%
Long Term Care Hospital:
- Days 1-60: $203 daily copay in 2023
- Days 61-90: $406 daily copay in 2023
- After day 90: You pay full cost unless secondary insurance covers
Always provide any secondary insurance details upfront to avoid surprise bills. Understanding coverage and proactively managing post-acute care bills makes the process much smoother. Seek assistance if you have trouble navigating Medicare claims or appeals.
Concurrent & Group Therapy Limit
The PDPM combined limit for both concurrent (1 therapist with 2 patients doing different activities) and group therapy (1 therapist with 2â6 patients doing the same or similar activities) canât equal more than 25% of the therapy that SNF patients get for each therapy discipline.
The PPS Discharge Assessment checks therapy limit compliance and includes the number of minutes per mode, per discipline, for the entire PPS stay.
Intermittent Skilled Nursing Care
We define intermittent SN care as care that patients need less than 7 days each week or less than 8 hours each day for periods of 21 days or less (with extensions in exceptional circumstances requiring more limited and predictable care).
To meet intermittent SN care requirements, patients must need a medically predictable recurring SN service, which typically occurs when a patient needs an SN service at least once every 60 days. The exception to the intermittent requirement is daily SN services for diabetic patients unable to administer their insulin (when they donât have an able and willing caregiver).
We cover home health aide services if a patient qualifies for the home health benefit. These services can include:
- Personal care
- Help with activities that support SN services
- Simple dressing changes
- Assistance with medications that are ordinarily self-administered and donât require the skills of a licensed nurse
- Prosthetic or orthotic device personal care
To provide these services, a home health aide must meet all these criteria:
- Be certified with competency evaluation requirements
- Provide hands-on, personal care or services that help treat a patientâs illness or injury, or maintain a patientâs health
- Perform tasks allowed only under state law
Orders for home health aide services must show how often patients need these services. A registered nurse or other skilled professional must perform on-site supervision of the home health aide at least every 14 days if the patient gets SN, PT, OT, or SLP services. In rare instances outside the HHAâs control, we allow 1 virtual supervisory visit per 60-day episode of care, which HHAs must document in the patientâs medical record.
We cover medical social services when all these criteria are met:
- The patient is eligible for the home health benefit
- The plan of care explains why only a qualified medical social worker or social work assistant, under the supervision of a qualified medical social worker, can safely and effectively provide services the patient needs
- Services resolve social or emotional problems that complicate a patientâs medical condition or recovery rate
Services using telecommunications technology must be indicated on the plan of care and can include:
- Remote patient monitoring, defined as collecting physiologic data (for example, electrocardiogram, blood pressure, glucose monitoring) digitally stored or transmitted by the patient or caregivers, or both, and sent to the HHAs
- Teletypewriter (TTY)
- Real-time interaction between the patient and clinician via 2-way audio-video.
Services provided by telecommunications technology arenât separately billable and canât be counted as a visit for payment or eligibility requirements. Visits to a patientâs home solely to supply, connect, or train them on remote patient monitoring equipment, without providing another skilled service, arenât separately billable.
Physicians or allowed practitioners can include the use of telecommunications technologies for the provision of home health services in the home health plan of care. Payment conditions include:
- The physician or allowed practitioner must include remote patient monitoring in the plan of care or other services via telecommunications system or audio-only technology
- HHAs canât substitute telecommunications or audio-only technology for a home visit as part of the plan of care, patient eligibility, or payment
- Telecommunications or audio-only technologies must meet patient-specific needs identified in the comprehensive assessment
The Post Acute Care Perspective on Bundled Payments
FAQ
What happens under the post-acute payment reform?
What does Pam stand for in hospital?
What is the Medicare post-acute transfer rule?
How are hospitals paid by Medicare?
How to pay for care after hospitalization in an acute care hospital?
One issue in the current discussion is how to pay for care after hospitalization in an acute care hospital, so-called post-acute care (PAC). “ Bundling” post-acute care is an approach that pays a fixed amount for all services provided to a patient after hospitalization for a defined period of time.
Does Medicare pay for acute inpatient care?
Hospitals contract with Medicare to furnish acute inpatient hospital care and agree to accept pre-determined acute IPPS rates as payment in full. 60-day lifetime reserve. Patient illness episodes begin on admission and end after 60 days post-hospitalization or after Skilled Nursing Facility (SNF) discharge.
How does Medicare adjust IPPs payments to acute inpatient hospitals?
Medicare adjusts a portion of operating IPPS payments to acute inpatient hospitals upward or downward for hospitals eligible for value-based incentive payments, based on their performance on a set of quality measures. Medicare reduces a portion of eligible hospitals’ operating IPPS payments for excess readmissions.
Do acute care hospitals qualify for Outlier payments?
Acute care hospitals can qualify for outlier payments for extremely costly cases. Hospitals that train residents in approved Graduate Medical Education (GME) programs get a separate payment for the direct cost of training residents, referred to as direct GME.
How does a hospital bill a Medicare patient?
The hospital submits a bill to their Medicare Administrative Contractor (MAC) for each Medicare patient treated. Based on the billing information, the MAC categorizes the case into a DRG. The base payment rate, or standardized amount (a dollar figure), includes a labor-related and nonlabor-related share.
Can acute care hospitals Bill a discharge to Medicare Part B?
Acute care hospitals cannot separately bill these services to Medicare Part B. The Centers for Medicare & Medicaid Services (CMS) assigns discharges to diagnosis-related groups (DRGs). A DRG is a grouping of similar clinical conditions (diagnoses) and the service procedures furnished during the inpatient hospital stay.