By submitting a UB-04, whether electronically or via direct data entry, the Medicare biller is certifying that all the information on the form is correct and complete. While a simple mistake on one claim is unlikely to be considered fraudulent billing, a pattern of mistakes (especially inflated charges) probably will be. As such, a review of UB-04 claim elements must be included in the monthly triple-check process.
There are several major operational and care governance systems SNFs can implement to facilitate the development and maintenance of dedicated CB processes, as well as to promote compliance in any number of facility domains. The two most prominent examples of such systems include:
the compliance and ethics program
the quality assurance and performance improvement (QAPI) program
Each of which not only holds significant regulatory clout, but also bridges distinct methodologies to provide dynamic frameworks for facility-wide compliance. In addition, although each program operates independently, when both are implemented at a facility, they can complement, support, and fuel the initiatives of one another, advancing an organization’s culture of shared responsibility and compliance—characteristics that are as important to the Medicare billing program as they are to any other area of SNF operations.