Common consolidated billing issues facing SNFs

Consolidated billing can be a challenge for any facility, and many SNFs continue to face confusion over which services are included or excluded. "Confusion over consolidated billing could result in missed reimbursement opportunities and rejected claims," says Maureen McCarthy, RN, BS, vice president of clinical reimbursement at National Healthcare Associates and president of Celtic Consulting in Goshen, Connecticut.

The following is a list of common consolidated billing questions facilities are facing and what your SNF can do to address these issues today.

1. I can’t find the Medicare fee schedule for a given charge from the hospital. What do I do? How much do I owe the hospital?

When a facility gets a bill for consolidated billing from a hospital, it usually does not have the fee-for-service reimbursement amount specifically listed. Instead, it will list the complete amount, including the hospital’s allowable markup for the services provided.

"Many facilities have a difficult time realizing how much they should be paying the hospital," says McCarthy.

Facilities often have trouble finding the codes to bill for the correct service. Here’s an example: A hospital bills a facility for hyperbaric chamber services. The bill amount was listed as $ 7,000. The question for the facility to consider is:

• What exactly are we being billed for?
• How much would Medicare pay for these services?

When faced with questions like these, the first step facilities should take is to determine where they need to look up the billing codes. Most facilities may access CMS’ physician fee schedule lookup. This tool, which can be found at www.cms.gov/apps/physician-fee-schedule/overview.aspx, will help you understand many of the charges billed by the hospital.

It is important to note that there are numerous sources of Medicare allowable payments outside the physician fee schedule, according to Bill Ulrich, president of Consolidated Billing Services, Inc., in Spokane, Washington. These include:

• Ambulance services
• Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
• Parenteral and enteral nutrition (PEN)
• Drug services
• Clinical laboratory services
• Ambulatory Payment Classification (APC)
• Splints, casts, etc.

For these services, there is no single or correct payment option, and there are a number of places facilities may need to look outside of the physician fee schedule.

In answering the question, "How much do I pay?" many facilities are missing a critical first step: Put "under arrangement" transactions in place with outside providers of services, including hospitals, says Ulrich. "CMS says that the entity shall look to the SNF for payment and they have told the SNF it must pay, but never has CMS said, at what level," he explains. "It’s the ‘arrangement’ that sets price, and absent that, state law controls cases where there is a payment dispute. Although we all encourage it, one cannot assume you pay the fee schedule or the fee schedule less co-pay."

2. Do I pay the technical component or the professional component of a provided service? What is the difference between these two components?

This question relates to any of the consolidated billing portion or Medicare Part B services. Under consolidated billing, the SNF is only responsible for paying the technical component of a bill?not the professional component, which is billed by the vendor straight to Medicare Part B.

When billing Medicare, vendors will receive payments under their own provider numbers because they are providing the professional service separately. The SNF has an arrangement with the vendor to supply the service to the resident, so you are only responsible for the technical component.

"The most important thing you can do to avoid confusion in this area of consolidated billing is to provide education on what these two components are and how they involve the SNF," McCarthy says.

Along with education of these components, a related issue facilities face is being asked to pay "facility fees," according to Ulrich. "While CMS says professional fees are not bundled, the hospital and ambulatory surgical center (ASC) bill for the facility portion of the professional services using the professional service code," Ulrich says. "It is important to understand that when the SNF is billed for one of these codes by the hospital or ASC they are not seeking reimbursement for the professional component but rather for the facility overhead associated with the services."

3. Are all forms of chemotherapy excluded under consolidated billing? What happens if the resident changes the chemotherapy they receive after admission to the SNF?

While the SNF Help file for consolidated billing provides information on chemotherapy drugs, the variety of drug treatments can cause confusion for billers when using consolidated billing.

"If a patient is on one type of chemotherapy when they are admitted to a SNF, it does not mean that they will stay on the same chemotherapy treatment throughout their stay," says McCarthy. "Their treatments may change and this is very important to understand."

Certain types of chemotherapy may be excluded under consolidated billing; however, other types are included and are reimbursable. This often leaves billers asking "Do I have to pay for it or not?"

"Many facilities may shy away from taking chemo patients because they were under the assumption that chemo was not paid for," McCarthy says. "This is incorrect?some of it is paid for, and facilities need to be aware of the differences."

When working with a chemotherapy patient, either the billers or the admissions staff?depending on who has the responsibility?should begin by contacting the provider from which they are getting their chemotherapy. This may be a hospital, chemotherapy center, cancer center, physician’s office, etc., to find out exactly which type of chemotherapy medication they are receiving.

"The provider was likely billing someone prior to that patient coming into the SNF, so if you can get the code that they are billing under, you can use that information to look up the type of chemotherapy provided," says McCarthy.

Speak to the physician prior to admission to determine:

• The likelihood that the patient will switch the type of chemotherapy he or she is receiving
• How long he or she will be on current chemotherapy medication and/or others

The goal of these questions is to help your facility understand what your cost will be for the length of the resident’s stay.

4. How far back can the hospital or physician provider go to send my facility a bill for any given service under consolidated billing? Is there an expiration date for submitting a bill?

There is not actually a window or a closing date for this, according to McCarthy. "We only have 120 days to adjust a Medicare claim, but we are receiving bills for people who have had stays back in 2010."

In the past, SNFs were not receiving a lot of bills because hospitals were being paid by a Medicare carrier and their business facilities were being paid by a fiscal intermediary. The records between the two were not overlapping, so both facilities were billing and all of the claims, regardless of duplication, were accepted.

Since the billing has become more transparent through reform efforts, SNFs are seeing more bills from hospitals. "When a hospital initially submits a bill, they may not be aware that the patient is or was a Medicare beneficiary," McCarthy says. "Then when their claim is denied, it’s not until they get back around to dealing with it that the SNF will see the bill. It generally shouldn’t take that long, but sometimes there are cases when it does."

Consider the following example: A person is in a no-fault auto accident. The no-fault insurance company says that it will pay for the necessary medical services. The capitated amount the insurance company is providing runs out prior to all of the services provided and the resident is switched over to Medicare Part A. The facility does not find out about the transition to Part A until after the initial bill has been sent.

It is particularly important to be aware of this when you are dealing with a situation where the payer source changes, says McCarthy. "Whether the resident is using auto insurance, Worker’s Compensation insurance, or another form of insurance, if they then ran out of money and switched to Medicare while in a stay at the facility, you don’t find that out until later," she explains.

5. Do I still have to pay a bill if the patient has already discharged or if they have expired?

Yes, in this situation, facilities must still pay for the billed services, if they received the services while covered under Medicare Part A. "Even if the resident owes your facility money, the facility still has to pay these bills," McCarthy says.

6. Is the ambulance ride covered?

Ambulance services are not categorically excluded from consolidated billing, according to CMS. However, certain types of ambulance transportation are separately billable in specific situations. According to CMS, these situations include:

• An ambulance trip that transports a beneficiary from the SNF at the end of a stay, when it occurs in connection with one of the following events, is not subject to consolidated billing.
  • A trip for an inpatient admission to a Medicare-participating hospital or critical access hospital (CAH)
  • A trip to the beneficiary’s home to receive services from a Medicare-participating home health agency under a plan of care
  • A trip to a Medicare-participating hospital or CAH for the specific purpose of receiving emergency services or certain other intensive outpatient services that are not included in the SNF’s comprehensive care plan
  • A formal discharge (or other departure) from the SNF that is not followed by readmission to that or another SNF by midnight of that same day
• An ambulance trip from the SNF to the hospital for the receipt of excluded types of outpatient hospital services. Since a beneficiary’s departure from the SNF to receive excluded outpatient hospital services is considered to end the beneficiary’s status as a SNF resident for consolidated billing purposes, any associated ambulance trips are excluded as well. Moreover, once the beneficiary’s SNF resident status has ended in this situation, it does not resume until the point at which the beneficiary actually arrives back at the SNF; accordingly, the return ambulance trip from the hospital to the SNF would also be excluded from consolidated billing.
• When a beneficiary leaves the SNF to receive off-site services other than the excluded types of outpatient hospital services described previously and then returns to the SNF, he or she retains the status of a SNF resident with respect to the services furnished during the absence from the SNF. Accordingly, ambulance services provided in connection with these services would remain subject to consolidated billing, even if the purpose of the trip is to receive a particular type of service (such as a physician service) that is excluded from consolidated billing.
• When an individual leaves a SNF via ambulance and does not return to that or another SNF by midnight, the day is not a covered Part A day, and CB would not apply. However, a beneficiary’s departure from a SNF is not considered to be a "final" departure for CB purposes if he or she is readmitted to that or another SNF by midnight of the same day. Therefore, when a beneficiary travels directly from SNF 1 and is admitted to SNF 2 by midnight of the same day, that day is a covered Part A day for the beneficiary, and CB applies.
  • A medically necessary ambulance trip would be bundled back to SNF 1 since the beneficiary would continue to be considered a resident of SNF 1 (for CB purposes) up until the actual point of admission to SNF 2. However, it should be noted that in addition to the "medical necessity" criterion pertaining specifically to ambulance transports under the SNF benefit (i.e., the patient’s medical condition is such that transportation by any means other than ambulance would be contraindicated), coverage in this context also involves the underlying requirement of being reasonable and necessary for diagnosing or treating the patient’s condition.
  • For example, a transfer between two SNFs would be considered reasonable and necessary in a situation where needed care is unavailable at the originating SNF, thus necessitating a transfer to the receiving SNF in order to obtain that care.
  • By contrast, a SNF-to-SNF transfer that is prompted by non-medical considerations (such as a patient’s personal preference to be placed in the receiving SNF) is not considered reasonable and necessary for diagnosing or treating thepatient’s condition and, thus, would not be bundled back to the originating SNF.
• If a SNF’s Part A resident requires transportation to a physician’s office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated), then the ambulance roundtrip is the responsibility of the SNF and is included in the PPS rate.
• Medicare does not provide any coverage at all under Part A or Part B for any non-ambulance forms of transportation, such as ambulette, wheelchair van, or litter van. In order for the Part A SNF benefit to cover transportation via ambulance, the ambulance transportation must be medically necessary. This means that in a situation where it is medically feasible to transport a SNF resident by means other than an ambulance, ambulance service will not be covered.

As with other situations of non-coverage, where the resident may be financially liable, the SNF must provide appropriate notification to the resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility’s per diem rate.

7. Do I have to adjust my paid claims to show the charges for a late bill from a bundled service?

As mentioned previously, SNFs only have 120 days to adjust a claim, but it would be in the provider’s best interest to ensure that all of the services paid for by the SNF for a particular resident under consolidated billing are stated, according to McCarthy. This is important because that will accurately document the amount?in services and dollars?that your facility is spending on Medicare patients.

This information should be included in your cost report under the different revenue codes. "A common problem we see here is related to ambulance services," McCarthy says. "The problem is that the ambulance providers don’t send their billed claims until the SNFs bills have already gone out." As a result, many facilities aren’t adding this information to their claim because it is significantly later and it is already a paid claim.

Just remember that all of the charges that resident incurs for Medicare Part A and B should be reflected on the claim.

8. Should I post all ancillary services my resident receives on my monthly claims?

Yes, all of the ancillary services should be included on monthly claims.

While ancillary service providers are a lot later to send the information to facilities, billers still need to show CMS all of the services that the facility is spending on Medicare covered patients. This is necessary to ensure that each patient is actually receiving the services they require.

9. Are FDA-approved drugs covered by Medicare if a resident is prescribed the drug for an off-label treatment?

There is a growing number of SNF’s residents that are being prescribed FDA-approved drugs for off-label conditions, according to Ulrich. "These off-label uses can really add up when the SNF is not aware of the coverage limitations set by CMS," Ulrich says.

For example, consider the drug Basiliximab (Simulect®), which was FDA-approved on May 12, 1998 for the following indicated use: kidney transplant?prophylaxis of acute organ rejection in patients receiving renal transplantation when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids. The Medicare allowable single dose cost for Basiliximab is $ 2,442.92 per 20mg (vial), which can bundled to the SNF.

However, Simulect® is also commonly used to treat the following (off-label) conditions:

• Atopic dermatitis
• Psoriasis
• Ulcerative colitis
• Uveitis
• Scleromyxedema
• Graft versus host disease (a complication that may occur after a stem cell or bone marrow transplant)
• Prevention of liver (and other organs) transplant rejection

The off-label treatments are not Medicare-approved costs.

HCPro.com – Billing Alert for Long-Term Care