Jeannine LeCompte, Publishing and Research Coordinator
Skilled nursing facilities (SNFs) are under a federally-mandated legal obligation to ensure that all financial processes are in alignment with the compliance regulations as specified by the Centers for Medicare & Medicaid Services (CMS). As an overall rule, billing claims must be accurate, based upon medically necessary items and services rendered or costs incurred, and substantiated by verifiable documentation.
SNFs must ensure that all documentation complies with existing statutory and legal requirements. This means providing prompt, complete, and accurate billing for resident services.
A system must be in place to ensure that billing is made only for services actually provided, directly or under contract, pursuant to all terms and conditions specified by the government or third-party payer, and consistent with industry practice.
A checking process should also be in place to ensure that no false or misleading entries are made on bills or claim forms, and that no employee, knowingly or otherwise, engages in any arrangement that results in such prohibited acts.
SNFs must be on the lookout for indications of false claims and billing fraud. The most common indicators include overtly false statements supporting claims for payment, misrepresentation of material facts, concealment of material facts, and in many cases, the theft of benefits of payments from the party entitled to receive them.
Other billing issues to be on the lookout for include intentional or unintentional claims to Medicare Part A for residents who are not eligible for Part A coverage, and the submission of claims for services or supplies that are not medically necessary, or that were not ordered by the resident’s physician or other authorized caregiver.
SNFs must also be aware that it is sometimes possible for staff to inadvertently submit claims for individual items or services when such items or services either are included in the facility’s per diem rate for a resident, or are of the type that may be billed only as a unit and not unbundled and billed separately in order to increase the charges.
Finally, SNFs must make sure that no inaccurate or misleading information is used to determine the Patient-Driven Payment Model (PDPM) classification, or other resident payment or acuity classification scale score or ranking assigned to the resident, including, but not limited to, misrepresenting a resident’s medical condition on the Minimum Data Set (MDS).
It is also a legal requirement to report any false billing practices, even if they have been created inadvertently. If an employee has any reason to believe that anyone is engaging in false billing practices, that employee should immediately report the practice to his or her immediate supervisor, the compliance hotline, the compliance officer, or any of the management staff designated to receive such reports verbally or in writing.
