Jeannine LeCompte, Publishing and Research Coordinator
Medicare- and Medicaid-approved skilled nursing facilities (SNFs) must have a billing management system in place that can provide a complete overview of all services delivered to each resident. This system should be able to ensure a single view of each resident’s details, the clinical service areas involved, and be integrated with the electronic claims submission process.
In addition, it must be able to provide a full reconciliation of all billing and costs. This is to help prevent the submission of false claims to the Centers for Medicare & Medicaid Services (CMS). It should be kept in mind that CMS does not differentiate in terms of illegality between deliberate false claims and “accidental” false claims. Both are actionable, even if the latter has slightly less onerous repercussions.
Apart from the data capture system, the billing process should also consist of the following elements:
– Properly trained personnel who are in charge of collecting and correctly analyzing data. They should be able to spot discrepancies before they become serious, and be able to perform internal and external data validation.
– Personnel who can detect SNF exposure resulting from the use of—and billing for—therapies which are inconsistent with CMS’s Patient-Driven Payment Model (PDPM) rules; or who can detect the overutilization of services billed on a fee-for-service basis under “Part B” (medically necessary and preventative services). In addition, personnel should have the ability to spot so-called “stinting,” or the provision of inadequate therapy services to residents covered by Part A payments.
– A written policy and procedure which requires therapy contractors to provide complete documentation of each resident’s services.
– A process whereby there is regular reconciliation of the physician’s orders and the services provided. This includes a full assessment, made in conjunction with the ordering physician, of the medical necessity of such services.
– A process through which it can be independently established that the services are in fact being provided (for example, family or resident interviews).
Be on the lookout for the most common errors in the billing process, which include:
- The submission of claims for
- Items or services not ordered
- Medicare Part A for residents who are not eligible for Part A coverage
- Items or services not actually rendered or provided as claimed
- Equipment, medical supplies, and services that are medically unnecessary
- Duplicate billing
- A failure to refund credit balances
Such errors are viewed as fraud and waste by the Office of the Inspector General, even if they are not deliberate, and will result in penalties.
Finally, the SNF’s written policies and procedures should have a corrective action plan in place to address all billing issues which may arise.
