Navigating the myriad rules, policies, and special cases that shape skilled nursing facility (SNF) consolidated billing (CB)—including distinguishing between services that are included in consolidated billing and ones that must be billed for separately—can be daunting, but learning to do so is critical for facilities. Achieving compliance in the CB domain is not only requisite for receiving earned reimbursement, but it can also influence the outcome of a SNF’s Centers for Medicare & Medicaid Services (CMS) audits, as well as prevent fraud and abuse–related Medicare infractions that can carry serious ramifications, including steep penalties, exclusion from the program, imprisonment, or any combination of these.
“Compliance” is one of our favorite buzzwords these days. But what does it mean? According to Merriam-Webster, compliance is “conformity in fulfilling official requirements.” Completion of the UB-04 for Medicare billing in the SNF definitely fits in the category of official requirements. How can the billing office ensure it is in compliance? One way is by performing its own internal audit, not just of individual claims, but of its claims completion process. Before looking at individual claims, it is important to determine if the process by which the items get to the claim is working properly. While your exact methods will differ depending on the specific computer system, method of tracking census and demographics, and method of obtaining ancillary charge information from outside vendors, the overall principles remain the same.
In the OIG report, Skilled Nursing Facility Billing for Changes in Therapy, published in June, findings showed that CMS implemented new policies (fiscal years [FY] 2011–2012) to address concerns that billing by SNFs did not adequately reflect changes in the amount of therapy that a beneficiary receives during a SNF stay.
On April 16, President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 (H.R.2) into law. The move gained national attention both within and beyond the healthcare provider community for its effective repeal of the sustainable growth rate (SGR) formula—a payment methodology intended to tamp down physician spending by tying Medicare reimbursement in the pricy sector to economic growth factors. But provider advocates say the irreparably flawed formula fell out of sync with soaring healthcare costs shortly after its enactment by the Balanced Budget Act (BBA) of 1997, thereby threatening physicians’ operations and beneficiaries’ access to essential primary care. MACRA—known colloquially as the “doc fix” bill for its physician reimbursement safeguards—replaces the SGR formula with a more timely payment strategy.