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CPAs & ADVISORS

HEALTHCARE GROUPJulie Bilyeu, DirectorLisa McIntire, CPA, Senior Managing Consultant

MEDICARE MAKEOVER

CONSOLIDATED BILLING: TRIMMING THE FAT

Consolidated Billing refers to Items and services that are considered covered under the Part A PPS scope even if the SNF does not directly provide those services

Items and services that will be SNF responsibility should be determined prior to admission

Develop policies and procedures for determining SNF responsibility and paying related invoices

CONSOLIDATED BILLING

Major Category ExclusionsDetermining the place of service

Category I has to be provided in hospital or CAHObtain procedure codes

Categories of exclusions are further broken down into excluded codes (outpatient surgery listed as inclusions)

Link to major category list and exclusions list by HCPChttp://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2013-Annual-Update.htm


Part BIf patient resides in a Medicare certified bed Part B therapy must be billed by the SNF

Barium swallow- STIf patient is in a non-certified section of the Facility or a true outpatient, therapy can be billed by therapy provider or SNF

23X bill type for outpatient therapy services


General ExclusionsProfessional services

For diagnostic tests/procedures SNF is responsible only for the technical component (modifier TC) not the professional component of the code (modifier 26)SNF is not responsible for hospital treatment rooms

Emergency servicesSNF not responsible for emergency services including ambulance transportation


Ambulance TransportationSNF Responsible

Related to a non excluded routine serviceWhen transferring to another SNF (Transferring SNF Responsible)

Exclusions from SNF responsibilityRelated to an excluded major category and was medically necessary

EmergencyDialysis

Upon admission to SNF

Non ambulance transportationThese forms may include:

Wheelchair vansAmbulettesFacility van

SNF may charge patientRecommend giving patient notice of exclusion from Medicare benefit



Provider ResponsibilitiesNotifying other providers/suppliers of a covered stayEntering into agreements with outside providers/suppliers

CMS does not determine the rate of payment but if a SNF has a history of not covering included services CMS may find them to be out of compliance with the Medicare program

Link to sample notice and agreement forms:http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/BestPractices.html


Determining the Medicare allowableFee schedules available on CMS website

Physicians fee schedule look upLab fee scheduleDME- prosthetic/orthotic & suppliesDrug average price scheduleReasonable charge for casts/splintsOutpatient hospital


Medicare non covered servicesDepending on SNF arrangement may be billable to patient if proper notice is provided http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Items_and_Services_Not_Covered_Under_Medicare_BookletICN906765.pdf

Non ambulance transportationEye exams-for fitting/prescribing/changing glassesDental services related to care/treatment/removal of teethHearing Aids

ADMISSIONS/INTAKE: AUGMENTING PATIENT FILES

Payer verification and eligibilityPayer websites/ClearinghouseMedicare Common Working File (to be terminated in 2014)

Completion of required paperwork/Admissions agreementKnowledge of payer type and coverage criteriaWell defined admissions procedures/checklist

Who is responsible for entry of information into softwareProcesses for maintaining financial information

Manual/Electronic/Network storage

ADMISSIONS/INTAKE

Medicare AQualifying hospital stay(minimum 3 consecutive days)

Impact of RAC audit of hospital stayImpact of observation daysAccounting for other skilled stays (SNU/Swing bed)

Verifying requirements for skilled careDaily skilled nursing servicesRehabilitation 5 days per week

ADMISSIONS/INTAKE

Medicare BTherapy cap usage

$1900 therapy capTherapy threshold

$3700Mandatory medical review (Post payment except for demonstration states effective April 1)

RAC Prepayment demonstration states- Texas

ADMISSIONS/INTAKE

Supplemental insurance- Copies of cards are keyMedigap versus other insurance

http://www.cms.gov/Medicare/Health-Plans/http://www.cms.govhttp://www.cms.gov/Medicare/Health-Plans/Medigap/index.html?redirect

ADMISSIONS/INTAKE

Managed CareImportance of recognizing enrollment prior to admissionMaintaining and updating contracts Pre-Authorization

Frequency of authorizationTimely filing guidelinesCoverage criteria

Level of care as defined in contractCompliance claim requirement to Medicare

04 Condition code

ADMISSIONS/INTAKE

Managed CareMethod of payment

Level of careChargesPer diemPPS (note CMS enforcement of MA plans to report PPS codes 12/31/13)

PART A BILLING STRUGGLES

Unscheduled assessments may take over payment window of a scheduled assessmentUnderstanding billing rules for combined assessments Possibility of one assessment being billed with 2 different HIPPS codes

Understanding when to bill therapy versus non therapy HIPPS


Change of therapy (COT) being retrospectivePotential need to adjust prior month claim

Increased risk of early/late/missed assessments and how to bill impacted claims

Unscheduled- Early/Late bill default number of days out of compliance (when missed MDS would have controlled payment)Scheduled- Early bill default number of days early/late bill default up to late ARDMissed= Provider liability, send covered claim with span code 77 and dates applicable to liability

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Understanding how to bill Unscheduled AssessmentsEnd of therapy (EOT)End of therapy Resumptive (EOT-R)Start of therapy (SOT)

Short StayChange of therapy (COT)

EOT OMRA - EXAMPLE

30-Day Window

Grace Days

Day Day Day Day Day Day Day Day Day Day Day30 31 32 33 34 35 36 37 38 39 40

Last Day

Therapy1 2 3

EOT DUE

RHB RHB RHB RHB LB1

EOT-R OMRA - EXAMPLE

Day Day Day Day Day Day Day Day36 35 36 37 38 39 40 41

Last DayTherapy 1 2 3 Therapy

Resumes

EOT ARD

5 Consecutive Day Count

0 1 2 3 4 5

EOT-RDate

RVB RVB CC1 CC1 CC1 CC1 RVB RVB

SOT OMRA - EXAMPLE

5-Day Window

Regular Days

Grace Days

Day Day Day Day Day Day Day Day Day Day Day1 2 3 4 5 6 7 8 9 10 11

Therapy Eval 5-day

ARDSOT ARD

CC1 CC1 CC1RHB

COT OMRA - EXAMPLE

30-Day Window

Grace Days

Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

30 DayARD 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3

335 310

RH

RH

RM

COT RUG

COT Due

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PART B BILLING STRUGGLES

Capturing modifiers on claimCCI edits- modifier 59Therapy cap exception- modifier KXMissing modifiers on claims= rejected servicesFunctional reporting (G codes)

Severity modifiers

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TRIPLE CHECK: REDUCING CLAIM ERRORS

Involvement of interdisciplinary team, nursing, therapy and billing to review claims prior to submission to payersTriple check is in addition to regular Medicare meetings throughout the month with the interdisciplinary teamClaims should be prepared and brought to the triple check meeting for reviewChecklist should be used and signed off (especially if performing any pieces offsite)

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TRIPLE CHECK

Common items to review:Necessary documentation has been signed/dated by physicianMDS have been submitted/accepted/and validation report has been checked for re-calculationsPatient demographic informationCensus dataCharges

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TRIPLE CHECK

Common items to review:HIPPS code/ARD/and payment datesQualifying stay for Part ADiagnosis code- relevance/sequencing/specificationOccurrence codesCondition codesPart B modifiersPart B G codes

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A/R MANAGEMENT: MAINTAINING A SVELTE AGING

Days outstanding vary by payer typeMedicare/private pay/Medicaid

30 days (should be resolved prior to next billing cycle)Insurance primary

30 days if able to file electronically60 days if filing paper

Co-Insurance- Must first wait for primary payer to pay60 days if filing electronic or auto-crossover

Identify crossover status on remittance advice90 days if filing paper

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A/R MANAGEMENT

Policies and procedures should be developed for follow up and tracking of unpaid balances

Accounts receivable softwareUsing collection notesSetting user tasks/follow up dates

Paper systemTickler fileAdding appointments to email/calendar

Excel TrackingAbility to export data from most A/R systems

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A/R MANAGEMENT

Medicare Follow upEDI acceptance verificationDaily follow up via DDE

Used to make corrections/adjustments/cancelsTracking policy for claims in medical review or appealsTracking for Medicare secondary payer claimsEducation

Subscribing to ListservsContractor callsCMS Open door forum

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A/R MANAGEMENT

Insurance Follow upClearinghousePayer websiteInvolving provider rep. when neededInvolving state insurance commissioner when neededFor Medicare replacement plans involving your local CMS office managed care plans division when neededStaying up on contracts and addendums

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A/R MANAGEMENT

AccountabilityScheduling consistent aging meetings between billing and executive leadershipDeadlines for month end close

Maintaining accurate A/RUpdating Medicare/Managed Care Rates

Part A OctoberPart B JanuaryPart A coinsurance January

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A/R MANAGEMENT

Maintaining accurate A/RPolicies/Procedures for contractual adjustments and write offs

Authorizing staff responsible for making entriesSetting a dollar threshold for levels of approvalDesignating a person to review entries for accuracyDetermining reports that should be reviewed monthly to catch all adjustment/write off entries

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A/R MANAGEMENT

Sequestration2% reduction effective April 1, 2013 DOSMedicare A and BManaged Care depending on payerDoes not impact coinsurance portion of payment

Part B MPPRPractice expense reduced by 50% effective April 1, 2013 DOS

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A/R MANAGEMENT

Understanding Medicare Remittance AdviceNon covered charges Part A= typically sequestrationNon covered charges Part B= MPPR, sequestration, charges rejected for missing modifiers

Verify all services were covered prior to adjusting A/RLink to universal RA codes

http://www.wpc-edi.com/reference/

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A/R MANAGEMENT

Medicare Reimbursable bad debtOnly Part A coinsurance is Exhibit 5 eligible

Coinsurance related to Medicare replacement plans does not count

Develop a system for tracking throughout the yearRoutine write offsKeep a file for copies of support such as payer denials, copies of private statements, etc.

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A/R MANAGEMENT

Medicare Reimbursable bad debtNon dual eligible (Private pay due)

Must have been billed at least 3 times“Reasonable and Customary attempts” to collect must have been taken and documentedDebt must remain unpaid more than 120 days from the date first billedWrite off date must be in applicable cost report yearPayment effective with FY-2013 reduced to 65% (63% after sequestration)

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A/R MANAGEMENT

Medicare Reimbursable bad debtDual eligible- Medicaid non payment varies by state

Proof of non payment- copy of remittance advice with correct denial reason code for legislative non payment

Denial for billing error or timely filing would not suffice

Write off date must be in applicable cost report yearPayment reduction

FY 2013 88% (86% after sequestration)FY 2014 76% (74% after sequestration)FY 2015 65% (63% after sequestration)

QUESTIONS

Lisa McIntire, CPA- Senior Managing Consultant, BKD [email protected]

Julie Bilyeu- Director, BKD [email protected]

THANK YOU

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atx13 - "the medicare makeover & avoid unnecessary costs and get everything you’ve...

Economy & Finance

snf responsibility

snf responsible exclusions

snf arrangement

outpatient therapy services

consolidated billing

covered services

services items

diagnostic testsprocedures