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MEDICARE CONSOLIDATED BILLING

MEDICARE CONSOLIDATED BILLING. PART IV PRACTICAL APPLICATION. Developed by Sandy Sage, R.N. Why are SNF and HH Consolidated Billing rules important to my hospital?. “Under Arrangement”. CONTRACTS. Negotiated by your Administration

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MEDICARE CONSOLIDATED BILLING

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  1. MEDICARE CONSOLIDATED BILLING PART IV PRACTICAL APPLICATION Developed by Sandy Sage, R.N.

  2. Why are SNF and HH Consolidated Billing rules important to my hospital?

  3. “Under Arrangement”

  4. CONTRACTS • Negotiated by your Administration • May want to be familiar with who has contracts and who doesn’t

  5. NEGOTIATED RATES • Rates that are specified in your contracts • Rates may be different for each contract

  6. NEGOTIATED RATES • Most SNF or HH rates are negotiated based on Medicare OPPS rates and fee schedules.

  7. What if no arrangements or contracts have been negotiated between your hospital and a SNF or HH?

  8. REGISTRATION RESPONSIBILITY 1. Determine where a patient originated from.

  9. REGISTRATION RESPONSIBILITY If the patient originated from a Nursing Home, the level of care must be determined.

  10. REGISTRATION RESPONSIBILITY Remember that levels of care can change from day to day! NEVER ASSUME!

  11. REGISTRATION RESPONSIBILITY 2. Determine who the primary payer will be.

  12. PRIMARY PAYER • Origin of patient • Type of service ordered

  13. PRIMARY PAYER • Will you bill it to Medicare, Home Health Agency or to the Skilled Nursing Facility?

  14. HOME HEALTH CONSOLIDATED BILLING SERVICES

  15. SNF CONSOLIDATED BILLING SERVICES

  16. SNF CONSOLIDATED BILLING A good rule of thumb is to know your high dollar services that are excluded from SNF consolidated billing. Print Transmittal A-00-01 and keep it handy if you need to.

  17. SNF Responsibility • Arrangements • Pay for services provided

  18. What happens if we get it wrong? What if we double bill Medicare?

  19. CWF REJECT EDITS • When the CWF receives a bill from the SNF that a patient has been admitted in a Part A stay, that SNF stay is posted to the CWF history.

  20. CWF REJECT EDITS • CWF will apply reject edits to any claims received after the SNF stay is posted that have dates of service during the period of the SNF stay.

  21. CWF REJECT EDITS • These reject edits will continue until the CWF receives a discharge date, date of death or the covered number of SNF days has been used.

  22. CWF REJECT EDITS • Your FI must deny line item services that should have been consolidated and paid by the SNF. • The FI must pay the line items that are for excluded services.

  23. CWF REJECT EDITS • Some claims may be received by Medicare prior to the SNF notifying the CWF of a SNF Part A stay. • The CWF will go back and search for any claims paid prior to this notification.

  24. Denial Messages • Adjustment Reason 109: Claim not covered by this payer/contractor. You must send the claim to the correct contractor.

  25. Denial Messages • Remark Code N73: “A SNF is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents.”

  26. Denial Messages • Remark Code MA78: “The patient overpaid you. You must issue a refund within 30 days for the difference between the allowed amount and the amount paid by the patient.”

  27. Medicare Summary Notice • Medicare will notify the beneficiary to be expecting a refund from you. The MSN will tell them the amount to expect in a refund.

  28. Home Health Edits • Similar to the SNF edits!

  29. BILLING STAFF • Your Business Office staff will THANK YOU for making sure that consolidated billing rules are understood and followed, starting at the point of registration!

  30. REVIEW • Contracts and arrangements for payment are negotiated by your administration. • You need to be familiar with who has made arrangements with your facility.

  31. REVIEW • Two of the big responsibilities on the registration staff are to determine where the patient originated from and to determine who the primary payer is.

  32. REVIEW • The SNF is responsible for making “arrangements” with outside providers. • Hospitals are responsible for compliant billing.

  33. Learning Outcomes • Explain when and why consolidated billing was implemented. • Discuss what is included and excluded from SNF and HHA consolidated billing payments. • Recognize admission source codes and discover why they are important. • Restate what hospital registration responsibilities are and why they are important if a patient is in a PPS stay.

  34. References: www.cms.gov https://www.cms.gov/SNFPPS/05_ConsolidatedBilling.asp https://www.cms.gov/HomeHealthPPS/ Contact: Sandy Sage R.N. ssage@dodgecountyhospital.com

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