Skilled Nursing Facilities Billing Services

Skilled Nursing Facility (SNF) Consolidated Billing (CB)

Consolidated Billing Background

Prior to the Balanced Budget Act of 1997 (BBA), an SNF could elect to furnish services to a resident in a covered Part A stay, either: directly, using its own resources; through the SNF’s transfer agreement hospital; or under arrangements with an independent therapist (for physical, occupational, and speech therapy services). In each of these circumstances, the SNF billed Medicare Part A for the services.

However, the SNF also had the further option of “unbundling” a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself.  This practice created several problems, including the following:

  • Potential for duplicate (Parts A/B) billing if both the SNF and outside supplier billed;
  • An increased out-of-pocket liability incurred by the beneficiary for the Part B deductible and coinsurance even if only the supplier billed; and
  • A dispersal of responsibility for resident care among various outside suppliers adversely affected the quality (coordination of care) and program integrity, as documented in reports by both the Office of the Inspector General (OIG) and the Government Accountability Office (GAO)

Congress then enacted the Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b), and it contains a Consolidated Billing (CB) requirement for SNFs.  Under the CB requirement, an SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services listed below).

CB eliminates the potential for duplicative billings for the same service to the Part A fiscal intermediary by the SNF and the Part B carrier by an outside supplier. It also enhances the SNF’s capacity to meet its existing responsibility to oversee and coordinate the total package of care that each of its residents receives.

Overview of Skilled Nursing Facility (SNF) Consolidated Billing (CB)

In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare-covered SNF stay be included in a bundled prospective payment made through the Part a Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part a MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in an SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in Part A covered SNF stay which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board are not.

The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part an SNF stay and physical, occupational, and speech therapy services received during a non-covered stay.

Exception:

There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable. For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

  • physician’s professional services;
  • certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
  • certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and round-trip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive 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.

For Medicare beneficiaries in a non-covered stay, only therapy services are subject to consolidated billing. All other covered SNF services for these beneficiaries can be separately billed to and paid by the Medicare contractor.

Medical billing and coding for skilled nursing facilities (SNFs) are complicated. Reimbursement for services received in an SNF is subject to an increasing number of regulatory restrictions, beginning with the Balanced Budget Act of 1997. In an effort to reduce potential fraud and abuse due to double billing by healthcare providers, SNFs currently bill Medicare under a Prospective Payment System (PPS) similar to the way inpatient facilities are reimbursed for medically necessary care to patients.

MedicalBillersandCoders (MBC) has helped nursing centers both in rural and urban US across all 50 US states, to improve their revenues by reducing reimbursement rejection rates and increasing their focus on nursing services. MBC’s billers and coders have extensive knowledge of billing and coding intricacies so that we can take care of the entire cycle of billing and coding needs starting from identifying patient eligibility for reimbursement to accurately separating items covered by Medicare A and Medicare B. We also perform post-claim-submission follow-ups to ensure timely reimbursement of payments by CMS. To know more about our SNF medical billing services you can contact us at 888-357-3226/ info@medicalbillersandcoders.com

Reference:

SNF Consolidated Billing

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