F0571

D

Improper Private-Pay Billing for Medicare-Covered Stay Extension

Walnut Creek, California Survey Completed on 02-05-2026

Penalty

No penalty information released

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.