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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
CONSOLIDATED BILLING
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
CONSOLIDATED BILLING
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
CONSOLIDATED BILLING
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
CONSOLIDATED BILLING
CONSOLIDATED BILLING
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
CONSOLIDATED BILLING
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
CONSOLIDATED BILLING
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
BREAK
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
PART A BILLING STRUGGLES
PART A BILLING STRUGGLES
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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PART A BILLING STRUGGLES
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)
29
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
30
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
31
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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