Palmetto denials for no MD order "admit to skilled care."

Palmetto for a long time has been denying SNF claims because there is no order to admit to skilled care.  They cite Fed Reg title 42 483.40 when denying.  Here is that reg:
https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec483-40.pdf

It does not require an order to "admit to skilled care" and you will win if you are willing to take it to the second level, the QIC.  This is the third try, after the initial denial and the redetermination to the MAC.  If you go to the QIC, which is Maximus,  you will win.

On an "Ask the Contractor"  call with Palmetto recently, this happened to a friend of mine:  I pulled this from her email to me.

Last week, one member of our team sat in on an Ask the Contractor call with reps from the different appeal levels. She provided the contractor with the template she is using to appeal the L1 and L2 denials we are getting routinely from Palmetto for not having a specific “Admit to skill care” order articulated even though there is a valid SNF cert and orders that meet the immediate needs of the resident. When she  brought this up on the call, the rep for Palmetto stated that based on Fed Reg title 42 483.40, there has to be an order that the physician writes that specifically states Admit to SNF.  If they don’t see this exactly, then it is denied.  When she mentioned the overturn at QIC level, the response (& you will love this) was that Palmetto has different guidelines to follow than the QIC level for reviewing.   The “good news” is that they are allowing us to submit our concern/complaint with examples for review and clarification. Will let you know how that goes.


So, folks,  as much as it nauseates me to say this,  we need to just write "admit to skilled care" orders if you are in Palmetto's jurisdiction.  It is not worth two appeals  to win this.  We need to fight this through associations and stake holder organizations.    They are keeping hundreds of thousands of dollars over this issue.  

If they are pulling old records and the order isn't there,  you are not out of compliance, but you will lose the first level appeal (which is conveniently back to Palmetto) and you will win at Maximus, the QIC.  Quote the reg found at the link above.