Improper Private-Pay Billing for Medicare-Covered Stay Extension
Summary
The deficiency involves the facility’s failure to limit charges against a resident’s personal funds for services covered by Medicare. A resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and had full Medicare coverage for 100 days through Kaiser upon admission. A NOMNC dated 3/17/23 indicated Medicare-covered services would end on 3/20/23 with discharge planned for 3/21/23, but this NOMNC was unsigned and lacked attestation. Despite this, the facility treated the NOMNC as effective and changed the resident’s payer status to private pay effective 3/21/23, based on the unsigned NOMNC and without providing the resident or resident representative with a notice of private pay costs. On 3/20/23, the resident experienced oxygen desaturation, was transferred to the hospital, and then returned to the facility early on 3/21/23. Progress notes showed that the discharge to a board and care was placed on hold for observation after the emergency room visit, and the attending physician ordered STAT labs and a chest x-ray, followed by continued monitoring and a later plan for discharge with home health and PCP follow-up. The resident ultimately remained in the facility and was discharged to a board and care on 3/24/23. During this extended stay, the Admissions Coordinator stated that if a resident returns from the hospital with remaining Medicare days, coverage should continue automatically, and acknowledged uncertainty about what happened with this resident’s coverage, as Medicare days were still remaining when the NOMNC was issued. The Business Office Manager and Traveling Business Office Manager reported that the facility did not request authorization from Kaiser for the resident’s continued stay after the hospital return and did not obtain an updated NOMNC with a new discharge date. Kaiser’s referral message on 3/21/23 documented a discharge date of 3/21/23 with 3/20/23 as the last covered day, and there was no documented authorization request by the facility. Relying on the unsigned NOMNC and without a Financial Responsibility Form or prior notification of non-covered services as required by the facility’s contract with Kaiser and its own policy on notice of covered and non-covered services, the facility billed the resident’s representative for three days of room and board and generated multiple collection letters before Kaiser ultimately paid the facility. This resulted in unnecessary billing, inconvenience, and potential emotional distress to the resident’s representative.
Penalty
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The facility improperly charged four residents’ trust accounts for private room and board during a month when each had documented Medi-Cal coverage. Business records showed that each resident’s trust account was debited the same substantial amount for private room and board while Eligibility Responses confirmed Medi-Cal benefits for that period, and payer setup information or billing practices reflected private pay status instead of Medi-Cal. The BOM acknowledged that these residents were switched from Medi-Cal to private pay despite having billable Medi-Cal benefits and that their trust funds should not have been charged, and the ADM confirmed residents are not supposed to be billed for Medi-Cal-covered services. The facility’s admission agreement also stated that a Medi-Cal-participating facility may not require a resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
A resident was incorrectly billed for services that were covered by insurance after a successful appeal of a Medicare Non-Coverage notice. Due to failures in communication and documentation review, the facility changed the payer status to private pay/Medicaid pending and charged the resident's account, resulting in a significant outstanding balance despite insurance coverage being in place.
Three residents with cognitive impairments were not properly informed of their monthly personal fund amounts and did not consistently receive their trust fund disbursements. Facility staff were unclear about representative payee responsibilities and failed to notify residents about the management of their funds, resulting in confusion and lack of access to entitled monies.
A resident with COPD, who was cognitively intact, had $20.00 deducted monthly from her personal needs allowance (PNA) by the facility to pay off a debt, despite Medicaid covering her care costs. The resident was not informed that she was not required to use her PNA for this purpose, and the deductions continued for nearly two years, violating regulations on resident fund management and rights.
A resident with Medicaid coverage was charged for new eyeglasses using her personal needs allowance, despite the service being covered by Medicaid. The facility deducted payments for the glasses and an insurance premium from the resident's trust account, leaving her without personal spending money for several months. The NHA confirmed that these charges should not have been taken from the resident's personal funds.
A resident and their representative were not informed of specific charges for services not covered by insurance or private pay agreements. Only the daily room and board rate was disclosed, and additional service costs, such as therapy, were not communicated before the resident incurred them. This resulted in confusion and unmet expectations when services were discontinued and charges were not clearly explained.
Improper Charging of Resident Trust Funds for Medi-Cal-Covered Room and Board
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal funds from being charged for services covered by Medi-Cal. For four residents whose records were reviewed, the facility debited their trust accounts for private room and board charges for a month in which they had documented Medi-Cal coverage. Facility business records, including the Trust - Transaction History and Activity Reports, showed that each of these residents’ trust accounts was debited $16,197.50 for private room and board for the same month. Eligibility Response documents dated at the beginning of that month indicated that each of these residents had Medi-Cal covered benefits for that period. Resident 7 was re-admitted with diagnoses including dementia, schizophrenia, and bipolar disorder, and had a BIMS score indicating severe cognitive impairment. Despite an Eligibility Response showing Medi-Cal coverage for the month in question, the Payer Setup Information showed that this resident was billed as private pay, and the trust account was debited $16,197.50 for private room and board. Resident 10, admitted with dementia and a psychotic disorder and documented to have fluctuating capacity but a BIMS score indicating cognitive intactness, similarly had Medi-Cal coverage per the Eligibility Response, yet the Payer Setup Information listed private pay status and the trust account was debited the same amount for private room and board. Resident 11, re-admitted with metabolic encephalopathy and dementia and documented as having capacity to make decisions, also had a Trust - Transaction History showing a $16,197.50 debit for private room and board for the month, while an Eligibility Response confirmed Medi-Cal coverage for that same period. Resident 12, re-admitted with metabolic encephalopathy, dementia, and altered mental status, had severe cognitive impairment per BIMS and a daughter listed as the responsible party. This resident’s Trust - Transaction History and Care Activity Report showed a $16,197.50 debit for private room and board for the month, despite an Eligibility Response confirming Medi-Cal benefits and Payer Setup Information indicating the resident was billed as private pay. In interviews, the Business Office Manager explained that the facility’s process is to recommend residents enroll in Medi-Cal as secondary insurance to avoid private pay charges when Medicare coverage ends, and stated that residents are only transferred to private pay when they do not have secondary insurance. The Business Office Manager acknowledged that on the first day of the month in question, each of the four residents was switched from Medi-Cal to private pay despite documented evidence of billable Medi-Cal benefits for that month, and that their trust accounts should not have been charged $16,197.50 for private room and board. The Administrator similarly stated that residents are not supposed to be charged for Medi-Cal covered benefits and confirmed that these four residents should not have been switched to private pay to cover services that Medi-Cal would have covered. The facility’s standard admission agreement also stated that no Medi-Cal-participating facility may require any resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
Resident Billed in Error for Covered Services After Successful Appeal
Penalty
Summary
The facility failed to ensure accurate billing practices by charging a resident's account for services that were covered by insurance after the resident successfully appealed a Notice of Medicare Non-Coverage (NOMNC). The resident was admitted under skilled nursing care following hospitalization and received a NOMNC, which was subsequently appealed. The appeal was successful, with the Quality Improvement Organization (QIO) determining that ending services was not appropriate due to the facility's failure to provide required documentation in a timely manner. Despite this, the facility transitioned the resident to Private Pay/Medicaid Pending status and began billing at a private pay rate, resulting in a significant outstanding balance. The error occurred because the facility did not properly communicate the appeal outcome or update the payer source accordingly. Staff failed to read and act on the QIO documentation, and the change in payer status was not relayed to the corporate Care Management Team. As a result, the resident was incorrectly billed for services that should have remained covered by insurance, leading to confusion and distress for the resident's representative, who was informed of a large outstanding balance and the need to remove the resident from the facility. The deficiency was attributed to corporate oversight and lack of communication between facility and corporate staff.
Failure to Inform and Distribute Resident Personal Funds
Penalty
Summary
The facility failed to properly inform residents of their monthly personal funds amounts and did not distribute personal fund monies as required. Three residents were affected by this deficiency. One resident, who had moderately impaired cognition, was unaware of why she was not receiving her monthly trust fund disbursement and had not authorized her nephew to manage her finances. The facility did not notify her that her monthly trust fund money was being given to her nephew, and there was confusion regarding who was the authorized representative payee for her Social Security and pension funds. Another resident, with severely impaired cognition, reported not receiving her trust fund money and was unaware of the amount she should receive. The facility staff stated that this resident's family was the representative payee, but the resident was not informed about this arrangement. A third resident, also with moderately impaired cognition, stated he had not received any trust fund money and expressed a desire to receive it. There was further confusion regarding the power of attorney and who was authorized to receive and manage his personal funds. Facility staff interviews and record reviews revealed inconsistent practices in the management and distribution of residents' personal funds. Staff were unclear about the proper procedures for handling Social Security and pension disbursements, and residents were not consistently informed about their personal fund accounts or monthly disbursements. The facility's own policy required uniform guidelines for the protection of personal funds, but these were not followed, resulting in residents not receiving or being informed about their entitled funds.
Improper Deduction of Medicaid Resident's Personal Needs Allowance for Facility Debt
Penalty
Summary
The facility failed to protect a resident's personal funds by charging her personal needs allowance (PNA) for services that are covered under Medicaid. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease (COPD), was admitted with a monthly income from which the PNA was deducted, as required by Medicaid regulations. Despite this, the facility deducted an additional $20.00 each month from the resident's PNA to pay off a debt owed to the facility, as agreed upon in a payment agreement signed by the resident. The deductions were made over a period of nearly two years, totaling $460.00, with additional unclear debits also noted in the resident's account. Interviews with the resident and facility staff confirmed that the resident was not informed that she was not obligated to pay her outstanding balance from her PNA funds. The business office manager acknowledged the arrangement and the facility's role as the resident's representative payee, while the nursing home administrator confirmed the ongoing deductions and the lack of documentation showing the resident was properly informed of her rights regarding the use of her PNA. The facility's actions were found to be in violation of state regulations regarding the management of resident funds and resident rights.
Improper Charges to Resident's Personal Funds for Medicaid-Covered Services
Penalty
Summary
A deficiency occurred when the facility charged a resident's personal funds for eyeglasses, a service that should have been covered by Medicaid. The resident, who is enrolled in a Medicaid plan, required new glasses following an acute vision problem and was sent to a local eye doctor. The resident reported that she had to pay for the glasses using her monthly personal needs allowance, which left her without personal spending money for several months. Clinical record review confirmed the resident's Medicaid coverage and the need for new glasses as documented by the eye doctor. Review of the resident's trust account showed deductions for medical bills related to the glasses and for an insurance premium that covers ancillary services such as vision. The Nursing Home Administrator confirmed that the charges for the glasses were taken from the resident's personal funds instead of being processed as an allowable medical expense under the resident's patient liability. The facility failed to ensure that the resident's personal needs allowance and trust account were managed in accordance with regulations, resulting in improper charges to the resident's personal funds for services covered by Medicaid.
Failure to Disclose Charges for Non-Covered Services
Penalty
Summary
The facility failed to notify a resident and their representative of the specific charges for services not covered under their Medicare Managed Care or private pay agreements. Upon admission, the resident received information about daily room rates and a list of potentially chargeable services, but the actual costs for these services were not provided. Staff confirmed that only the daily room and board charges and beauty salon fees were reviewed with residents, and that costs for medical supplies or therapy were not disclosed. When the resident's insurance coverage ended, an Advance Beneficiary Notice of Non-coverage (ABN) was issued, indicating the resident would be responsible for a daily rate, but did not specify charges for additional services such as therapy or medical supplies. The resident and their financial representative believed all previously received services, including therapy, would continue under private pay, as no separate charges were communicated. However, therapy services were discontinued after insurance authorization ended, and the facility did not provide advance notice of separate charges for these services. Staff interviews confirmed that residents only received information about additional charges after incurring them, and that the ABN did not clarify what was included in the daily rate. This lack of transparency led to confusion and unmet expectations regarding the continuation and cost of services.
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