The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation is announcing refinements to the design of the second year of the Medicare Advantage Value-Based Insurance Design (MA-VBID) model. The MA-VBID model is an opportunity for Medicare Advantage plans (MA plans), including Medicare Advantage plans offering Part D benefits (MA-PD plans), to offer clinically nuanced benefit packages aimed at improving quality of care while also reducing costs.
There are five major categories of consolidated billing (CB), each with specific compliance criteria. As each category is delineated, you should frame the individual service scope and billing requirements it contains in the context of your facility’s unique population demographics and operational realities to understand the immediate relevance, determine any potential implications, and earmark specific points that may inform future education and training initiatives.
On June 6, 2016 the Centers for Medicare & Medicaid Services (CMS) released a final rule improving how Medicare pays Accountable Care Organizations in the Medicare Shared Savings Program for delivering better patient care. Medicare is moving away from paying for each service a physician provides towards a system that rewards physicians for coordinating with each other. Accountable Care Organizations are a major part of that transition, rewarding providers that deliver high-quality, efficient, and coordinated care for patients.
In just six months, SNF providers will begin ushering in a new era of value-based payments and quality reporting, thanks to several proposed policy and payment changes for the coming year. Although facilities won’t see reimbursement changes based on these proposals until fiscal year (FY) 2018, both of the new programs outlined in the Federal Register propose data collection time tables that begin January 1, 2017, which will be used to make value-based payments in subsequent years.
One of the most common compliance risk areas facilities target in their programs today is Medicare billing practices—a focus that can compel SNFs to launch a range of proactive improvement initiatives, such as billing audits and compliance training to safeguard against fraud, waste, and abuse.
Effective billing begins before a resident ever steps foot in the nursing home. Verification of Medicare benefits and SNF eligibility sets the stage for proper service delivery and claims completion. Without this due diligence, SNFs may provide and bill for inappropriate care—actions that can incite a host of costly consequences.
Although most healthcare facilities, suppliers, and businesses comply with the letter of the law, some have taken advantage of every available loophole. To ensure that the program remains solvent in the future, the government is aggressively attempting to reduce costs. Simultaneously, oversight and enforcement measures and programs have been implemented to prevent fraud and abuse. Claims submitted for payment are being scrutinized more closely than in the past.
Admissions department and billing office staff know the importance of verifying benefits for prospective residents. By establishing a procedure to evaluate a beneficiary’s payer source prior to admission, SNFs can reduce possible claims adjudication issues and facilitate the receipt of payments in a timely manner.
SNF business offices all have a series of compliance checks and balances they do on a daily, weekly, and monthly basis. But do you realize you have them? And does the corporate compliance team know what you are doing so they can include your great work in their compliance program? If you are part of a larger organization and your compliance team is mostly in a different location, they may not be aware of all the daily compliance review you do. It is important to take a few minutes to document your processes to ensure that correct UB-04s are going out the door, and to share those processes with your compliance team.