SNFs see zero reimbursement value from no-pay bills and benefits exhaust claims, so no-pay bills often go overlooked. Billers are instead looking to deal with issues that will result in cash flow for the facility. So what exactly are no-pay bills, and where does a benefits exhaust situation come into play?
by Deborah Collum, national director of revenue cycle management at Covenant Retirement Communities and AMBR Advisory Board member
Implementing a revenue cycle management (RCM) model in your facility will help you streamline your billing process to prepare for the Patient-Driven Payment Model (PDPM) to be implemented October 1, 2019. If your billing office still follows an accounts receivable (AR) model that only focuses on outstanding accounts, you’re not alone—but it may be time for a change.
In the final 2018 outpatient prospective payment system (OPPS) rule released by CMS, total knee arthroplasty, also known as total knee replacement (TKA/TKR), was removed from the Medicare inpatient-only (IPO) list. The IPO list includes procedures that are only paid under the hospital inpatient prospective payment system.
CMS regulations require that a facility assessment be completed annually to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. These assessment findings can then be used to make decisions about direct care staff needs and capabilities needed to care for each resident. If current needs aren’t being met, nurse leadership may need to implement new competency development. This task doesn’t involve the billing department directly; however, billers, business office managers, and the finance department can support other departments through changes in the facility’s expenses that will help contribute to a healthier bottom line.
The UB-04 is a multipurpose claim form used for all Medicare providers, including home health agencies and hospitals, but not all fields apply to SNFs. SNFs must submit bills in sequence for each beneficiary they care for. Out-of-sequence bills will result in an error message similar to this: Bills for a continuous stay or admission must be submitted in the same sequence in which services are furnished. If the provider has not already done so, please submit the prior bill. Then, resubmit this bill after you receive the remittance advice for the prior bill. Billers for SNFs must understand the bill types and their codes to submit them in the correct sequence.
Between 2011 to 2016, Medicare fee-for-service drug spending increased from $17.6 billion to $28 billion under Medicare Part B. Medicare Part D total spending has almost doubled from 2010 to 2016, increasing from $77.5 billion to $146.1 billion, with costs projected to increase further, according to the Centers for Medicare & Medicaid Services (CMS). Drug prices for beneficiaries in the U.S. are also on the rise and can be found in places like Europe for up to 80% cheaper, according to NPR. The cause? A market full of hurdles and barriers to creating biosimilars (drugs with the same or similar active ingredients as the original and often available at a reduced price); current laws that prevent vendors from negotiating drug prices; and outrageous prices for essential drugs that treat ever-more-common chronic conditions, such as cancer, rheumatoid arthritis, and hepatitis C.
The Office of Inspector General’s (OIG) studies can serve as a good alert system for long-term care facilities as well as the regulators who monitor them. We’ve compiled a list of relevant reports and recommendations published by the OIG in 2018 to help you prioritize your quality and compliance goals for this year.
Surgical dressings are limited to primary dressings, which are therapeutic or protective coverings applied directly to wounds or lesions that are on the skin or are caused by an opening to the skin, and to secondary dressings that are therapeutic or protective (i.e., are needed to secure the primary dressing).