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Navigating the LTC technology landscape:How SNFs are using HIT, POC tools

Navigating the LTC technology landscape:How SNFs are using HIT, POC tools

When it comes to technology, SNFs and their fellow postacute care (PAC) providers are rapidly approaching a crossroads: Find a way to overcome resource gaps to speed adoption efforts, or risk facing new compliance issues down the line as the use of innovative technologies to facilitate data sharing, performance comparison, and patient-centered care across settings and sectors become staples in the modern provision of healthcare.

The increasing precedence of technology is not only reshaping traditional attitudes toward healthcare delivery along the continuum, but could derail providers that don’t keep pace with innovations that fuel new approaches.

“Technology has become a business imperative, frankly,” says Majd Alwan, PhD, senior vice president of technology at LeadingAge, a Washington, D.C.?based trade association for nonprofit aging services providers, and executive director of the organization’s Center for Aging Services Technologies (CAST). “Without the right technologies, you will not be getting in your referrals … either because you do not have the competencies and are ­costing your trading partners money … or because you don’t have the proper documentation and analytics to demonstrate that you have better results than competitors.”

 

Historic PAC gaps

Although legislators are working to catalyze technology adoption through policy and regulation, PAC providers have historically been passed over for the associated financial incentives (e.g., CMS’ twilighting electronic health record [EHR] incentive programs) in favor of their acute care counterparts.

Until recently, SNFs have also been overlooked in national research on technology adoption. Alwan says the most recent data on usage among nursing home providers across the country is a 2009 research paper whose findings are based on survey results from 2004.

But policymakers aren’t blind to these lapses, says Jennie Harvell, senior policy analyst in the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services (HHS). She explains that while widespread technology adoption initiatives have so far homed in on the acute and primary care spheres, PAC providers are increasingly the targets of federal grants awarded to state- and community-based implementation projects.

“I think [HHS] is aware of … who the EHR incentive programs targeted, and who the EHR incentive programs did not, and so they have made some grant programs available that support technology development and use by long-term and postacute care providers,” she says.

In addition, she explains that CMS reinvigorated national technology research efforts in the sector this year by launching a voluntary survey to analyze if and how PAC providers are using health information technology (HIT) to coordinate care transitions and support their clinical services?an effort that the agency hopes will help it better understand the current benefits and barriers to adoption. The survey will close on April 3.

 

Mounting incentives

CMS’ recent initiatives aren’t the only moves that suggest an increased push to understand and further flesh out the role technology plays in long-term care.

More legislative evidence includes the PAC-centered Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which sailed through a notoriously fragmented Congress last year and is slated to propel the development of standardized, interoperable assessment data for the sector.

Also in 2014, the Obama administration issued a handful of executive actions that CMS has begun using to recalibrate the star rating system featured on Nursing Home Compare.

The actions also allocated funding from the IMPACT Act to kick-start CMS’ development of an electronic reporting system that will collect nursing homes’ staffing numbers based on payroll data and post this information on Nursing Home Compare. Development is currently underway, and CMS expects to mandate nationwide nursing home reporting through the system by the end of fiscal year 2016.

In addition to setting-specific incentives on the horizon, Alwan says the overarching shift in care priorities illustrated by new payment and care delivery models offers significant indirect motivation for SNFs as well. He points to increasing opportunities for high-performing facilities to reap financial rewards and referrals through bundled payments, participation in accountable care organizations (ACO), and contributions to hospital success in readmission reduction programs.

 

Major technology landmarks in healthcare

Because of this increasing precedence, the healthcare technology market is awash with tools intended to spur operational efficiency and clinical success.

For example, according to the Office of the National Coordinator for Health Information Technology (ONC), HIT is an umbrella term that encompasses a host of technologies that can facilitate the storage, sharing, and analysis of health data by patients and their providers.

Notable HIT subsets and offshoots include:

  • Health information exchange (HIE). As its name suggests, HIE is a process through which patients and their providers securely access and share key medical information in an electronic format.
  • EHRs, which proponents say allow for increased organization and accuracy of patient information; better-informed decision-making and data sharing about a patient’s specific needs and conditions; streamlined administrative processes; and easier, more consistent compliance with new regulations.
  • Although used in many circles as a synonym for ­EHRs, electronic medical records (EMR) are actually scaled-back versions, according to the ONC. They are also digital iterations of patient charts, but unlike EHRs, they are often only used in their electronic form by a single provider because they are not necessarily interoperable. To share a patient’s EMR with other practices, a provider may need to print out and deliver relevant information by mail.

 

In addition to the broad collection and data sharing scope of HIT, there are also myriad established, evolving, and emerging technologies on the clinical end of the spectrum, including:

  • Point of care (POC) technology, which enables clinicians to electronically collect and measure essential patient information in the field
  • Telehealth, which encompasses mobile technology and connectivity devices that support long-distance clinical healthcare, education, and administrative efforts by remotely communicating healthcare data

 

The long-term care technology landscape

In the SNF arena, providers are using this growing array of dynamic technologies to different extents and with varying degrees of success, according to experts, who peg EHRs and POC as the most prevalent tools.

According to a December 2014 report by CAST and Chicago-based financial services provider Ziegler, 74.7% of the 150 largest nonprofit senior living communities across the country have adopted EMRs and/or EHRs.

Alwan attributes these high implementation rates to the abilities of these technologies to perform federally mandated assessments and feed payment claims?features that he says granted EHRs the first technological foothold in the industry.

But while certain providers have made significant headway in EHR adoption, other HIT facets remain ill-explored in the sector, according to Harvell.

For example, she says few SNFs currently have HIE systems to share discharge summaries with other settings. However, she expects?and hopes?to begin seeing more SNFs turn to such solutions as data sharing continues to gain traction throughout healthcare.

In addition, robust HIT systems can help providers keep track of other essential documentation, such as whether residents have completed advance directives?an increasing focus in the industry, says Elizabeth Babalola, MPH, research analyst at Princeton, New Jersey?based Mathematica Policy Research.

As for the other major technology category in the sector, the CAST and Ziegler report found that 76.6% of surveyed providers have already adopted POC or point of service documentation systems.

Experts say SNFs use POC technologies to monitor crucial care components, such as changes in condition and functional ability, thereby bolstering care planning, service delivery, and resident outcomes.

For example, Babalola points to medication reconciliation as a major focus in the POC realm.

Medication reconciliation is the process of comparing a patient’s new or revised medical orders at critical junctures (e.g., after care transitions or condition changes) to all of the medications that the individual has been taking to avoid triggering dangerous omissions, duplications, dosing errors, or drug interactions. Babalola says this practice is particularly critical for SNFs, whose residents are often on many medications at once, increasing the chances of harmful side effects and interactions. She explains that certain POC technologies can reduce these risks by tracking each patient’s list of prescriptions and alerting providers about any potential complications a new addition could carry.

Alwan says there’s also been an uptick in the adoption of emergency response systems among SNFs, such as bed, chair, and body alarms for residents at risk of falling, as well as devices aimed at managing wandering habits among individuals with dementia.

In addition, he sees the implementation of telehealth picking up speed, particularly among SNFs that have partnered with hospitals (especially through ACOs) to reduce hospitalizations. For example, he says some SNFs and hospitals share real-time video teleconsult services that allow physicians to perform virtual examinations on residents who are exhibiting potentially problematic symptoms?a practice that can circumvent unnecessary readmissions to the hospital.

 

Barriers to adoption

Despite the strides SNFs have made in certain areas of technology, they still face a host of obstacles that experts say can stall progress during any stage of adoption.

Experts unsurprisingly point to the various costs associated with adoption as some of the biggest barriers to technology usage, such as implementing and maintaining systems over time, converting paper records to electronic files, and training staff to use the new technology, says Babalola.

She adds that in addition to the direct costs associated with using dynamic new technologies, the cost of purchasing the underlying infrastructure to support them can stop some providers before they really get started?a problem she witnessed firsthand during recent research.

Babalola was the lead author of a June 2014 study that examined the baseline level of IT adoption among all 84 licensed nursing homes in Rhode Island between 2009 and 2011?a period just prior to the launch of a statewide initiative to incentivize the purchase and installation of technology in long-term care settings to facilitate the enrollment of residents in the state’s HIE program.

Prior to the launch of the incentive program, Babalola found that a staggering 64% of studied providers lacked computers with Internet access in all clinical areas of their facility, a shortcoming that she says underscores the importance of government backing in this domain.

“Having those funds available for nursing homes is a huge driver if you’re trying to improve technology adoption,” she explains.

Once providers do manage to secure the necessary framework, fair-weather vendors can still prevent them from seeing meaningful results, Babalola adds.

“A lot of vendors will be there for implementation and for setup, but you need someone who’s going to help you maintain the system over time,” she says.

In addition to patchy technical assistance, Alwan says shortfalls in the skill sets of clinical staff (e.g., due to the industry’s steep turnover rates) can also jeopardize the success of a new technology system. He underscores the importance of filling gaps in the competencies of clinicians, CNAs, and other essential frontline workers with ongoing training programs that emphasize innovative ways of thinking about care and methods for delivering it using the facility’s entire arsenal of resources.

The financial and operational barriers that pervade the SNF arena can be further exacerbated by certain provider characteristics, according to Alwan, who says research shows that being small, independent, and/or located in a rural area can impede technology implementation rates.

 

Getting started

Despite the additional challenges some providers may face when foraying into the technology sphere, Babalola maintains that most can benefit from implementation, particularly of EHRs. However, she points to one significant caveat: providers must act with foresight to achieve success. She underscores the need for providers to have a comprehensive action plan in place at the outset of adoption to fully integrate new systems into daily operations, which she says is the only way to realize the full potential of the investment.

“If [the technology is] not properly incorporated into the workflow of the facility, then you just have a computer there and some fancy software, but you’re not really making any meaningful impact,” she explains.

Consequently, she says plans should detail the specific reasons for adoption (i.e., how the new technology will improve operations, practices, and/or outcomes), articulate concrete methods for reaching these goals, and anticipate additional resources (e.g., underlying infrastructure, technical support, staff training, or adjustments in the scope of job responsibilities) that will be necessary to achieve success.

For SNFs who have already implemented EHRs, ­Alwan recommends expanding their utility of the system beyond its basic functionality.

“If [providers] start with EHRs that are interoperable, that are capable of exchanging information with other providers, participating in health information exchange activities would be the next step,” he says, explaining that providers can use more advanced reporting and analytics features to monitor key operational and clinical considerations, such as hospital readmission rates and number of referral sources.

In addition, Alwan points providers considering adoption of any kind to CAST’s website for access to information on understanding, planning for, choosing, and implementing an array of technologies. Resources include technology-specific materials (e.g., white papers, vendor feature matrices, provider case studies, and interactive selection tools) to aid decision-making in the EHR, telehealth, and medication reconciliation domains, as well as videos that illustrate how different types of technologies can enhance care delivery. This year, Alwan says CAST will add new resources for functional ­assessment and activity monitoring?centered technologies, as well as some to facilitate strategic IT planning.

 

Leveraging grant programs and outputs

In addition to identifying specific facility needs and creating tailored action plans, experts urge providers to keep an eye toward funding opportunities that can fuel adoption efforts.

Harvell recommends that SNFs find out more about applicable grant programs, which she says often produce inexpensive technology tools that may mitigate financial obstacles. In particular, she points to two recent state-level programs funded by ONC grants that have made promising technology strides:

  • In 2011, the ONC awarded more than $ 16 million to 10 states through its HIT Challenge Grant Program, explaining its goal was to “encourage breakthrough innovations for health information exchange that can be leveraged widely to support nationwide health information exchange and interoperability.”

Among the awardees was the Massachusetts Technology Park Corporation, which received two challenge grants totaling more than $ 3.3 million. With its winnings, the organization launched the Improving Massachusetts Post-Acute Care Transfers project (known by the now-familiar acronym IMPACT) to better care transitions by facilitating HIE between acute and postacute care providers, regardless of whether they use EHRs. To initiate this exchange, IMPACT staff developed system architecture called LAND and SEE, which allows providers to electronically create, send, and receive a Universal Transfer Form at a relatively low cost. PAC providers without EMR systems can also use the SEE tool to capture and collect electronic data about their patient populations, Harvell adds.

The awardees are currently piloting and further refining the tools developed through IMPACT in order to share them with other states and support affordable HIE along the continuum.

  • Through its Beacon Community Cooperative Agreement Program, ONC awarded an additional $ 250 million over the course of three years to 17 communities across the country that have already made headway in the development of EHRs and other HIE-focused systems to improve cost, quality, and population health, as well as to advance performance ­measurement and other technology initiatives in their localities.

The central Pennsylvania-based Keystone Beacon Community, recipient of more than $ 16 million in grant funding, developed KeyHIE Transform, a tool that parses CMS-required assessments for SNFs (MDS) and home health agencies (OASIS) for clinically relevant points of patient data, and translates this information into an interoperable electronic summary document. The transform tool is particularly useful for enabling interoperable HIE by PAC providers that don’t have EHR systems, Harvell says. She adds that use of the dynamic tool would cost less than $ 1,000 annually for a large SNF.

“It’s very, very, very affordable, and it’s an easy on-ramp to health information exchange for the long-term postacute care provider community,” she says.

 

Resounding legislative IMPACT

While SNFs’ access to grant opportunities may vary based on their location, Harvell says the phasing in of the IMPACT Act will have sweeping implications for the entire PAC community.

The legislation will first see in the development of standardized, interoperable data items for use on each of the disparate patient assessments that exist across the PAC sphere to promote cross-setting collaboration and care coordination. This stage, coupled with subsequent reporting to providers, the general public, and Congress, will allow CMS and other policymakers to identify gaps and best practices throughout the sector, compare performance between PAC settings, and continue developing new payment models.

In turn, Harvell thinks the legislation’s heavy emphasis on the creation and dissemination of data will inspire vendors to build more dexterous EHRs and will encourage providers to more readily embrace them?especially given the historic influence that CMS’ requirements for providers to electronically submit assessment data to receive payment have had on the development and usage of EHRs.

“The requirements to electronically transmit assessments have served as the backbone for many of these EHR products,” Harvell says, predicting that the IMPACT Act’s call for interoperability will prompt similar progress.

“I think the IMPACT Act has a lot of promise in terms of advancing the type of technology tools that are available and will be used in this sector,” she says.

HCPro.com – Billing Alert for Long-Term Care

Common consolidated billing issues facing SNFs

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