Each year, the Office of Inspector General (OIG) identfies government programs under the Department of Health and Human Services that are vulnerable to waste and abuse through erroneous claims. In several recent years, the OIG’s annual Work Plan has included an item to review a sample of Medicare claims submitted by SNFs is reviewed to determine not only the accuracy of coding for Medicare Part A claims but also claims for services under Part B during a Part A SNF covered stay, calculation of Medicare days as that number relates to no-pay bills, and Minimum Data Set (MDS) accuracy.
Hospitals and critical access hospitals (CAHs) are required to provide a MOON to Medicare beneficiaries (including Medicare Advantage health plan enrollees) informing them that they are outpatients receiving observation services and are not inpatients of a hospital or CAH.
Ambulance transfers are extremely expensive for SNFs and their Medicare Part A–covered patients. “The high costs associated with transfers create a significant financial risk for SNFs,” says Barbara Reimer, consultant with the Fox Group.
Ideally the admission is coded as soon as possible upon admission, prior to entry of orders in the electronic medical record (EMR). This may not be a complete listing but should include diagnosis to support medications and treatments being provided to the resident.
Are you in compliance with Qualified Medicare Beneficiary (QMB) billing requirements? People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.