Eliminating Skilled Nursing Facilities’ (SNFs) Medical Billing Complication

Medical billing for Skilled Nursing Facilities has undergone metamorphic changes ever since the Balanced Budget Act of 1997 came into effect 1998. One of the significant requirements under the new legislation is that Skilled Nursing Facilities are not permitted to unbundle services that are administered by contracted healthcare providers. As a result, most of the services provided to Medicare beneficiaries are to be bundled together and billed by SNFs under the Prospective Payment System (PPS) in one consolidated claim. The SNF concerned is then responsible to pay for contracted services out of the per diem rate that it earns for caring a Medicare beneficiary.

While this imposition may have helped reduce potential fraud and abuse due to double billing by healthcare providers, SNFs have certainly had a hard time in understanding:

  • What services are covered under consolidated billing
  • What is billable under Medicare Part A
  • What is billable under Medicare Part B
  • State-specific Medicaid protocols and methodologies for SNFs Medical Billing
  • Commercial health insurance plans and their dynamics

Though most the services offered to a resident under Medicare Part A are allowed to be included in the consolidated billing, certain services deemed costly or requiring specialization must not be appended with the consolidated billing. Generally, physician’s professional services; certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services; certain ambulance services, including transporting the beneficiary to the SNF initially, transporting from the SNF at the end of the stay (other than when involving transfer to another SNF), and transporting round-trip during the stay temporarily offsite to receive dialysis or certain types of intensive or emergency outpatient hospital services; erythropoietin for certain dialysis patients; certain chemotherapy drugs; certain chemotherapy administration services; radioisotope services; and customized prosthetic devices are excluded.

The services that are excluded under Medicare Part A should be billed under Medicare Part B, which allows medically necessary services to be reimbursed under the ‘Fee For Service’ (FFS) system. It is possible that SNFs may have not entirely been thorough with these procedures, resulting in billing inefficiencies.

Even as most of the SNFs need to bill Medicare Part A and Part B, there could be SNFs that operate under state-specific Medicaid ambit. And, because each of the 50 states in the U.S. may its own Medicaid program, SNFs should invariably have to bill under their state-specific Medicaid rules and regulations. This regions-specific compliance too may have had a considerable impact on SNFs billing.

Outside the public health insurance plans, SNFs encounter the second largest health insurance providers in commercial health insurance carriers. While CMS has set a uniform standard for reimbursements across the board, commercial plays may still have their own individualistic methods of SNF reimbursement. Thus, SNFs medical billing may have suffered from having to adapt to these multi-payer dynamics.

These SNF-related medical billing concerns necessitate the significance of SNF medical billing specialists that certified and competent to maneuver SNF medical billing executions under Medicare Part A, Part B, state-specific Medicaid programs, and the commercial health insurance environment. MBC has been versatile enough to solve medical billing issues regardless of location, size, or medical disciplines; practices across the 50 states in the U.S. continue to rely on us for remedial and transformational medical billing services. With our nation-wide resource-base adept at multi-component and multi-payer health insurance environments, SNFs should be able to put their medical billing complication to rest.