Have you reviewed your certification and recertification statements for Medicare skilled nursing care recently?   My recent experiences with Medicare payment denials have indicted this continues to be an area many providers should focus on for process improvement.  Denials based on certification and recertification statements cannot be appealed.  The risks associated with a breakdown of certification and recertification process can significantly impact the operations of a Skilled Nursing Facility (SNF).  Ensuring the certification and recertification statements for Medicare skilled nursing care are not only completed but accurately completed can prevent the loss of revenue.  A review of this critical process may be the difference between a payment and a denial.  As Skilled Nursing Facilities continue providing the highest quality care possible amid a myriad of budget cuts, preventing denials of payment has to be a priority.

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In the MLN Matters® Number SE 1428, CMS stated “SNF inpatient improper payment rate increased from 4.8 percent during the 2012 reporting period to 7.7 percent during the 2013 report period. A major source of improper payments stems from SNFs failure to obtain certification and recertification statements from physicians or NPPs”.  The recent denials I have reviewed would indicate the number of SNF inpatient improper payment has increased from the figures available from 2013.  Medicare revenue hinges on the individual facility’s ability to obtain accurate and appropriate certification and recertification statements from their physicians and nonphysician practitioners.

MLN Matters® Number SE 1428 outlined what is expected in both certification and recertification statements:

What is an Acceptable Certification Statement?

An acceptable certification statement must contain the following information:

• The individual needs skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services;
• Such services are required on a daily basis;
• Such services can only practically be provided in an SNF or swing-bed hospital on an inpatient basis;
• Such services are for an ongoing condition for which the individual received inpatient care in a hospital; and
• A dated signature of the certifying physician or NPP.

What is an Acceptable Re-certification Statement?

An acceptable recertification statement must contain the following information:

• The reasons for the continued need for post-hospital SNF care;
• The estimated time the individual will need to remain in the SNF;
• Plans for home care, if any;
• If the reason for continued need for services is a condition that arose after admission to the SNF (and while being treated for an ongoing condition for which the individual received inpatient care in a hospital) this must be indicated; and
• A dated signature of the recertifying physician or NPP.

Although CMS does not have a required format for obtaining certification and recertification statements, they have made the requirements for these statements clear.  If the certification or recertification statement is “Skilled for PT/OT”, the claim will undoubtedly be denied if/when it is reviewed by an auditor.  A savvy provider will be scrutinizing their certification and recertification statements frequently and, most importantly, before claims are submitted.