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ATX13 - "The Medicare Makeover & Avoid Unnecessary Costs and Get Everything You’ve Earned!"


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ATX13 - "The Medicare Makeover & Avoid Unnecessary Costs and Get Everything You’ve Earned!"

  1. 1. CPAs & ADVISORS experience clarity // HEALTHCARE GROUP Julie Bilyeu, Director Lisa McIntire, CPA, Senior Managing Consultant
  3. 3. 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
  4. 4. CONSOLIDATED BILLING Major Category Exclusions Determining the place of service Category I has to be provided in hospital or CAH Obtain 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 HCPC Billing/2013-Annual-Update.htm
  5. 5. CONSOLIDATED BILLING Part B If patient resides in a Medicare certified bed Part B therapy must be billed by the SNF Barium swallow- ST If 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
  6. 6. CONSOLIDATED BILLING General Exclusions Professional 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 services SNF not responsible for emergency services including ambulance transportation
  7. 7. CONSOLIDATED BILLING Ambulance Transportation SNF Responsible Related to a non excluded routine service When transferring to another SNF (Transferring SNF Responsible) Exclusions from SNF responsibility Related to an excluded major category and was medically necessary Emergency Dialysis Upon admission to SNF
  8. 8. CONSOLIDATED BILLING Non ambulance transportation These forms may include: Wheelchair vans Ambulettes Facility van SNF may charge patient Recommend giving patient notice of exclusion from Medicare benefit
  9. 9. CONSOLIDATED BILLING Provider Responsibilities Notifying other providers/suppliers of a covered stay Entering 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:
  10. 10. CONSOLIDATED BILLING Determining the Medicare allowable Fee schedules available on CMS website Physicians fee schedule look up Lab fee schedule DME- prosthetic/orthotic & supplies Drug average price schedule Reasonable charge for casts/splints Outpatient hospital
  11. 11. CONSOLIDATED BILLING Medicare non covered services Depending on SNF arrangement may be billable to patient if proper notice is provided d_Under_Medicare_BookletICN906765.pdf Non ambulance transportation Eye exams-for fitting/prescribing/changing glasses Dental services related to care/treatment/removal of teeth Hearing Aids
  12. 12. BREAK
  13. 13. ADMISSIONS/INTAKE: AUGMENTING PATIENT FILES Payer verification and eligibility Payer websites/Clearinghouse Medicare Common Working File (to be terminated in 2014) Completion of required paperwork/Admissions agreement Knowledge of payer type and coverage criteria Well defined admissions procedures/checklist Who is responsible for entry of information into software Processes for maintaining financial information Manual/Electronic/Network storage
  14. 14. ADMISSIONS/INTAKE Medicare A Qualifying hospital stay(minimum 3 consecutive days) Impact of RAC audit of hospital stay Impact of observation days Accounting for other skilled stays (SNU/Swing bed) Verifying requirements for skilled care Daily skilled nursing services Rehabilitation 5 days per week
  15. 15. ADMISSIONS/INTAKE Medicare B Therapy cap usage $1900 therapy cap Therapy threshold $3700 Mandatory medical review (Post payment except for demonstration states effective April 1) RAC Prepayment demonstration states- Texas
  16. 16. ADMISSIONS/INTAKE Supplemental insurance- Copies of cards are key Medigap versus other insurance
  17. 17. ADMISSIONS/INTAKE Managed Care Importance of recognizing enrollment prior to admission Maintaining and updating contracts Pre-Authorization Frequency of authorization Timely filing guidelines Coverage criteria Level of care as defined in contract Compliance claim requirement to Medicare 04 Condition code
  18. 18. ADMISSIONS/INTAKE Managed Care Method of payment Level of care Charges Per diem PPS (note CMS enforcement of MA plans to report PPS codes 12/31/13)
  19. 19. PART A BILLING STRUGGLES Unscheduled assessments may take over payment window of a scheduled assessment Understanding 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
  21. 21. PART A BILLING STRUGGLES Change of therapy (COT) being retrospective Potential 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 ARD Missed= Provider liability, send covered claim with span code 77 and dates applicable to liability
  22. 22. PART A BILLING STRUGGLES Understanding how to bill Unscheduled Assessments End of therapy (EOT) End of therapy Resumptive (EOT-R) Start of therapy (SOT) Short Stay Change of therapy (COT) 22
  23. 23. EOT OMRA - EXAMPLE 30-Day Window Grace Days Day 30 Day 31 Day 32 Day 33 Day 34 Day 35 Day 36 Last Day Therapy 1 2 3 EOT DUE RHB RHB RHB RHB LB1 Day 37 Day 38 Day 39 Day 40
  24. 24. EOT-R OMRA - EXAMPLE Day 35 Day 36 Day 37 Day 38 Last Day Therapy Day 36 1 2 Day 39 3 Day 40 Day 41 Therapy Resumes EOT ARD 5 Consecutive Day Count 0 1 2 3 4 5 EOT-R Date RVB RVB CC1 CC1 CC1 CC1 RVB RVB
  25. 25. SOT OMRA - EXAMPLE 5-Day Window Regular Days Day 1 Day 2 Day 3 Day 4 Therapy Eval CC1 CC1 CC1 RHB Grace Days Day 5 Day 6 Day 7 5-day ARD Day 8 Day 9 Day 10 SOT ARD Day 11
  26. 26. COT OMRA - EXAMPLE 30-Day Window Grace Days Day 30 30 Day ARD RH Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 1 2 3 4 5 6 7 1 335 2 3 4 5 6 7 310 RM RH COT RUG COT Due 1 2 3
  27. 27. PART B BILLING STRUGGLES Capturing modifiers on claim CCI edits- modifier 59 Therapy cap exception- modifier KX Missing modifiers on claims= rejected services Functional reporting (G codes) Severity modifiers 27
  28. 28. TRIPLE CHECK: REDUCING CLAIM ERRORS Involvement of interdisciplinary team, nursing, therapy and billing to review claims prior to submission to payers Triple check is in addition to regular Medicare meetings throughout the month with the interdisciplinary team Claims should be prepared and brought to the triple check meeting for review Checklist should be used and signed off (especially if performing any pieces offsite) 28
  29. 29. TRIPLE CHECK Common items to review: Necessary documentation has been signed/dated by physician MDS have been submitted/accepted/and validation report has been checked for re-calculations Patient demographic information Census data Charges 29
  30. 30. TRIPLE CHECK Common items to review: HIPPS code/ARD/and payment dates Qualifying stay for Part A Diagnosis code- relevance/sequencing/specification Occurrence codes Condition codes Part B modifiers Part B G codes 30
  31. 31. A/R MANAGEMENT: MAINTAINING A SVELTE AGING Days outstanding vary by payer type Medicare/private pay/Medicaid 30 days (should be resolved prior to next billing cycle) Insurance primary 30 days if able to file electronically 60 days if filing paper Co-Insurance- Must first wait for primary payer to pay 60 days if filing electronic or auto-crossover Identify crossover status on remittance advice 90 days if filing paper 31
  32. 32. A/R MANAGEMENT Policies and procedures should be developed for follow up and tracking of unpaid balances Accounts receivable software Using collection notes Setting user tasks/follow up dates Paper system Tickler file Adding appointments to email/calendar Excel Tracking Ability to export data from most A/R systems 32
  33. 33. A/R MANAGEMENT Medicare Follow up EDI acceptance verification Daily follow up via DDE Used to make corrections/adjustments/cancels Tracking policy for claims in medical review or appeals Tracking for Medicare secondary payer claims Education Subscribing to Listservs Contractor calls CMS Open door forum 33
  34. 34. A/R MANAGEMENT Insurance Follow up Clearinghouse Payer website Involving provider rep. when needed Involving state insurance commissioner when needed For Medicare replacement plans involving your local CMS office managed care plans division when needed Staying up on contracts and addendums 34
  35. 35. A/R MANAGEMENT Accountability Scheduling consistent aging meetings between billing and executive leadership Deadlines for month end close Maintaining accurate A/R Updating Medicare/Managed Care Rates Part A October Part B January Part A coinsurance January 35
  36. 36. A/R MANAGEMENT Maintaining accurate A/R Policies/Procedures for contractual adjustments and write offs Authorizing staff responsible for making entries Setting a dollar threshold for levels of approval Designating a person to review entries for accuracy Determining reports that should be reviewed monthly to catch all adjustment/write off entries 36
  37. 37. A/R MANAGEMENT Sequestration 2% reduction effective April 1, 2013 DOS Medicare A and B Managed Care depending on payer Does not impact coinsurance portion of payment Part B MPPR Practice expense reduced by 50% effective April 1, 2013 DOS 37
  38. 38. A/R MANAGEMENT Understanding Medicare Remittance Advice Non covered charges Part A= typically sequestration Non covered charges Part B= MPPR, sequestration, charges rejected for missing modifiers Verify all services were covered prior to adjusting A/R Link to universal RA codes 38
  39. 39. A/R MANAGEMENT Medicare Reimbursable bad debt Only Part A coinsurance is Exhibit 5 eligible Coinsurance related to Medicare replacement plans does not count Develop a system for tracking throughout the year Routine write offs Keep a file for copies of support such as payer denials, copies of private statements, etc. 39
  40. 40. A/R MANAGEMENT Medicare Reimbursable bad debt Non dual eligible (Private pay due) Must have been billed at least 3 times “Reasonable and Customary attempts” to collect must have been taken and documented Debt must remain unpaid more than 120 days from the date first billed Write off date must be in applicable cost report year Payment effective with FY-2013 reduced to 65% (63% after sequestration) 40
  41. 41. A/R MANAGEMENT Medicare Reimbursable bad debt Dual 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 year Payment reduction FY 2013 88% (86% after sequestration) FY 2014 76% (74% after sequestration) FY 2015 65% (63% after sequestration) 41
  42. 42. QUESTIONS Lisa McIntire, CPA- Senior Managing Consultant, BKD LLP 417.865.8701 Julie Bilyeu- Director, BKD LLP 417.865.8701
  43. 43. THANK YOU FOR MORE INFORMATION // For a complete list of our offices and subsidiaries, visit or contact: Name, Credentials // Title // 888.888.8888