Patient Driven Payment Model (PDPM) – Part 2

In our previous blog “PDPM Reimbursement Part 1”, we reviewed the clinical changes, the MDS Assessment Changes and their relation to generating the Patient Driven Payment Model (PDPM) HIPPS Code. In this blog we will be exploring and explaining the complexity of the new HIPPS Codes Components and the tables provided by CMS in the July 31, 2019 FY 2020 PDPM Final Rule release. These tables will be critical for determining and calculating Reimbursement.

An important change related to PDPM HIPPS Codes is they are comprised of a 4-digit Alpha Code and a 1-digit numeric code. The HIPPS Codes will still be generated based on the data recorded in the RAI/MDS Assessment Tool and produced when the Assessment is completed, locked and transmitted. The 5 Case-Mix Adjusted Care Components applied to the 4 Alpha codes are listed below and the 5th digit is the numeric code for the MDS Assessment Modifier. It is important to note that the 1st Alpha digit is shared by the PT and OT Care Components.

PDPM HIIPS Code Example = ABAC1

MDS Assessment
HIPPS Code Position PDPM Group Code Result PDPM Component
1st (Shared Alpha Code) A Physical Therapy – PT
1st (Shared Alpha Code) A Occupational Therapy – OT
2nd (Alpha Code) B Speech/Language Pathology – SLP
3rd (Alpha Code) A Clinical/Nursing RUG
4th (Alpha Code) C Non-Therapy Ancillaries (NTA)
5th (Numeric Code) 1 MDS Assessment Modifier

The Alpha Characters available as PDPM Group Codes for the PT & OT Component range from A-P, the ST Component range is from A-L, the Clinical Nursing Component Range is from A-Y and the Non-Therapy Ancillary Component Range is from A-F. This is significant because the new format for the HIPPS Code and the Components involved have a radical impact on the possible number of HIPPS Codes and corresponding Reimbursement rates available. Using a Permutations and Combinations Formula the conservative estimated number of possible variable HIPPS Codes could be 115,200.

No longer do you have 64 RUGs with a set rate for reimbursement, which in the past was easily loaded to your Billing Software System. Now, due to the large number of possible HIPPS Codes available it will take a series of complex calculations to determine the actual reimbursement rate based on the HIPPS Codes Combination Generated.

Like previous years, in the July 31, 2019, FY 2020 PDPM Final Rule CMS has provided a series of tables with the needed data to perform those complex calculations. The first two tables to be considered are the FY 2020 Unadjusted Federal Base Rate Per Diems for each of the 5 Case Mix Adjusted Components and the 1 Non-Case Mix Component.

Table 3—FY 2020 Unadjusted Federal Rate Per Diem—Urban

Rate component PT OT SLP Nursing NTA Non-case-mix
Per Diem Amount $60.75 $56.55 $22.68 $105.92 $79.91 $94.84

Table 4—FY 2020 Unadjusted Federal Rate Per Diem—Urban

Rate component PT OT SLP Nursing NTA Non-case-mix
Per Diem Amount $69.25 $63.60 $28.57 $101.20 $76.34 $96.59

The next table is the Proposed PDPM Standardization and Budget Neutrality Multipliers for each of the 5 Case Mix Components, (previously data for FY 2017 DOS only were published) the table has been updated to include Multipliers based on FY 2018 DOS Data. Each of the 5 Components has a corresponding standardization multiplier and a budget neutrality multiplier.

Table 5—Proposed PDPM Standardization and Budget Neutrality Multipliers

Component FY 2017 data FY 2018 data
Standardization multiplier Budget neutrality multiplier Standardization multiplier Budget neutrality multiplier
PT 1.031 1.458 1.028 1.463
OT 1.030 1.458 1.028 1.463
SLP 0.995 1.458 0.996 1.463
Nursing 0.995 1.458 0.996 1.463
NTA 0.817 1.458 0.811 1.463

This is where things start to get complicated, normally at this point CMS would provide the two Federally Adjusted RUG-IV Rate Tables, with PDPM and the new HIPPS Codes, CMS had to create new tables and they are very unlike the RUG-IV Rate Table. They are the PDPM Case-Mix Adjusted Federal Rates and Associated Indexes, one for Urban Locations and one for Rural Locations (Copies of these tables will be provided in our PDPM Reimbursement Part 3 Blog).

In each of these tables the first Column of the Table references the MDS Assessment PDPM Group Code. The next series of columns in the table are related to the 5 Case Mix Ad

Each of the Alpha Characters of the PDPM HIPPS Code determined by the RAI/MDS Assessment, is tied to the corresponding letter and component in the table to determine the Rate for that Component. The resulting rates of the 5 Components along with the Non-Case Mix Rate is added together to determine the PDPM Case-Mix Adjusted Per Diem Rate.

Be sure you don’t overlook, that the PT, OT and Non-Therapy Ancillary (NTA) Rates also must be multiplied by the Variable Per Diem (VPD) rate based on the length of stay. The Variable Per Diem (VPD) percentage rate is provided in yet another table.

We aren’t done yet! The PDPM Case-Mix Adjusted Per Diem Rate that was just calculated now must be broken down into Labor (76%) and Non-Labor (24%) portions to allow the Labor Portion to be multiplied by the Wage Index for the Current Year based on your SNF’s physical location. The Wage Index Percentage Table is still found by clicking on a Link which will take you to the appropriate table on the CMS.gov website. Finally, that rate will then have to be further adjusted for the 2% Sequestration Reduction, Value Based Program (VBP) Incentive Percentages and any penalty related to the Quality Reporting Program (QRP).

It is SNF Solutions’ opinion, that in order to determine reimbursement rates, calculate revenue and contractual adjustments for DOS 10/1/2019 and forward, billing software companies are going to have to load these tables into their software systems and write the programming to complete the complex calculations. Since the posting of Blog 1 of this series several of the commonly used billing software systems have released updates to their programs with instructions related to system or database setup changes that will be needed.

Additionally, to be sure that SNFs are billing correctly and receiving accurate reimbursement, they will need to ensure adequate education and training is provided to their Business Office staff and managers. These key staff members will need to understand the correlation of each one of the four Alpha Identifiers of the PDPM HIPPS Codes to the 5 Non-Case Mix Components, utilize the tables provided and be able to perform the calculations to determine if the correct reimbursement was received.

BUCKLE UP ITS GOING TO BE A VERY BUMPY RIDE!

We can help. Schedule a free consultation with us today.

In our PDPM Reimbursement Part 3 Blog we will be uploading copies of the tables referenced in this blog from the July 31, 2019 release of the FY 2020 PDPM Final Ruling and providing examples of the calculations required to determine reimbursement.

Patient Driven Payment Model (PDPM) – Part 1

brainstorming complicated pdpm changes for skilled nursing facilitiesPDPM is coming October 1, 2019, what does this mean to Skilled Nursing Facilities?

Are you prepared and ready for the changes that are involved?

This proposed change to how reimbursement for Skilled Nursing Facility care is determined is very complicated and will possibly reference topics and industry verbiage you may not be familiar with. One such topic that SNF-Solutions has already received questions about is what does Case-Mix Indexes/Adjustments and Non-Case Mix mean? The simplest explanation we can give is this:

The Centers for Medicare and Medicaid (CMS) and the federal government complete an annual review of the care provided to residents across the country. Using common, easily measurable, processes and procedures they would determine the Federal Base Rate for three care components Clinical, Therapy and Non-Case Mix. In recognition of the varying costs of care across the country and the varying level of care due to a resident’s health they allowed certain of these care components (Clinical and Therapy) to be adjusted if certain conditions are present in the resident’s care or health. These adjustments are a percentage that the Federal Base Rate is multiplied by and are called Case Mix Indexes or Adjustments. However, there is one care component that never gets adjusted and it has always been labeled the Non-Case Mix Component. This component is not considered direct patient care related but is the component for the cost of furnishing a location or facility for the resident to live in.

This information about Case-Mix Adjustments and Non-Case Mix Components has been used every year and is referenced in every Proposed and Final Rule FY Rate Notice but has never been as complicated and impactful as it will be with the new Patient Driven Payment Model (PDPM).

PDPM is a complete and comprehensive change from the RUG-IV Payment Models of the past two years. Previous RUG reimbursement models, including RUG IV, were primarily therapy driven, and the reason Skilled Nursing Facilities focused on the patients who needed the most therapy in order to receive the highest reimbursement available. CMS recognized this widespread practice and determined that things needed to change.

In May 2017 CMS first introduced and proposed a payment model that they called “Resident Classification System, Version-1“, or RCS-1. When first proposed this model was so complex it caused an outcry from the industry, resulting in the proposed release date originally planned for October 1, 2018 being delayed. CMS needed the additional time to allow for further evaluation and response to the numerous questions and proposed changes made by the industry. In July 2018 the model’s name was changed to the Patient Driven Payment Model (PDPM) and the release date updated to October 1, 2019.

From May 2017 through today, CMS has continued to make updates and has released several addendums with revised data. They have also held multiple open-door forums to address concerns and questions raised by the industry regarding PDPM. These addendums and open-door forums focused primarily on the clinical changes and impacts to ICD-10 Diagnosis Coding and Minimum Data Set (MDS) Assessment changes that would be needed, as well as how information would be gathered to be more reflective of a patient’s overall clinical condition.

The major change is that the new model will no longer utilize just the 3 currently used care components, Clinical, Therapy (these 2 were Case-Mix Adjusted) and Non-Case Mix. Instead, there will now be 5 Case-Mix Adjusted Care Components considered and 1 Non-Case Mix Component.

Each component will contribute to identifying the Health Insurance Prospective Payment Service (HIPPS) Code that determines reimbursement. Additionally, those 5 Case Mix Care Components will include additional detailed groupers (between 10-16 groupers) per component which will require additional entries in the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Assessment and supported by documentation recorded in the resident’s medical record.

The single most important contributing factor for PDPM is the proper identification of a resident’s admitting and treating ICD-10 Diagnosis Code, as it determines what happens next. All of the components, their groupers, the relevant Case Mix Adjustment Factors and data to be entered [in] the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Assessment are tied to and controlled by that initial ICD-10 Diagnosis Code.

Sounds complicated doesn’t it? IT IS! Which is why so many in our Industry have already begun the training needed to educate their nursing staff regarding these changes. Many administrators, executive directors, and owners of Skilled Nursing Facilities who don’t have the knowledge or resources to provide training and education or develop programs for these purposes, have already begun reaching out to various industry experts for assistance. It is vital that this training is provided to a SNF’s RAI/MDS nurse coordinators, medical records staff, director of nursing (DON), admission directors and business office staff.

If you have not begun or recognized the need for this training or don’t have the resources available to provide it in-house, there are many opportunities and webinars related to the clinical aspects of PDPM that have already been developed and are available through various organizations.

All previous addendums and Proposed Rule Notifications released did not include the details of how the clinical changes and the 5 Case Mix Adjusted Care Components and 1 Non-Case Mix Component would be used to determine actual HIPPS Codes and Reimbursement Rates. The Proposed Rule released on April 25, 2019 is the first to provide data and the formulas that will be used to determine actual Reimbursement Rates.

Unlike with previous FY Final Proposed Rule releases which provided an updated Rate Table, which listed each of the RUG-IV HIPPS Codes with their corresponding reimbursement rates, PDPM is not that simple. In the past this RUG-IV Rate Table was simply, easily and effectively uploaded by the SNFs to the various billing software systems available in our industry. The billing software system would then reference this data to calculate revenue and the appropriate RUG would be printed onto the UB-04 for submission to Medicare for reimbursement.

Due to the complexity of the data and the variable results possible from completion of the RAI/MDS Assessments related to the new Case Mix Components, the new Proposed Rule released on April 25, 2019 does not include one all inclusive, easily loadable table. Instead there are a series of tables with varying codes, rates, case mix adjustments and per diem percentage adjustments that will need to be referenced and factored through a series of calculations to determine the reimbursement codes and rates for services rendered.

SNF-Solutions invites you to join us on this journey of change, through a series of Blogs to be published over the next few months. These blogs will provide you with explanations and examples of how SNF billing reimbursement will be determined and calculated beginning October 1, 2019.

SNF Solutions Has a New Look

We don’t have to tell you that billing and collecting for skilled nursing facilities is complex. But it doesn’t have to be. We are committed to making this process as easy as possible for your organization, so you can get back to caring for your residents.

That starts with our website. We’ve created our new site to introduce the different ways that we can help you receive the money your SNF is owed. We walk every client through a three-step process:

  1. Get a free consultation. We talk about your need for outsourced billing, training for your staff, temporary help, or a review of your existing practices.
  2. Gather the details. This is where we make sure we have what we need to provide you with an effective solution to maximize your revenue.
  3. Get your money. Now to the good stuff. We will help you collect your missing payments, typically 5 – 10 times the cost.

The bottom line? It shouldn’t be complicated to get paid. With our new site, we’ve made it easy for you to understand exactly how we can help you.

Other features of our new website include:

Services – Curious about our areas of expertise? Learn more about the ways we can help you, from collections to consultation.

Resources – You’ll find a list of helpful organizations and websites in the SNF industry.

About Us – Learn more about the SNF Solutions story and meet our team members.

Blog – We tackle today’s issues in billing and collections to equip you to best serve your clients.

Our main goal is to make SNF billing and collections simpler for you. Our new website is just one of the ways that we are committed to doing this.

If you’d like to know more about how we can help your organization get paid on time, click here to schedule a free consultation or call us at 407.977.8878.

Do You Need to Look for a New Business Office Manager? (Part 2)

new business office manager

Though it may seem obvious that the most important factor in how a Business Office performs is the Business Office Manager. In Part 2 of our “Red Flag” Blog Series we consider this very critical staff member and the indicators that could be telling you might need to consider taking action.

In every Skilled Nursing Facility, the Business Office Manager’s performance is critical to the financial health, stability, and success of the facility. The Business Office Manger may not always be the source of any billing troubles however, they always set the tone in the office and are responsible for everyone under them.

A good Business Office Manager has to be capable of managing themselves, as well as the Business Office Staff. They need to be knowledgeable and experienced in the processes involved in SNF Billing. They are responsible for, and need to be held accountable for, completing accurate and timely billing and providing courteous and professional collections. They must also be able to identify and resolve obstacles to performing any assigned tasks. This is absolutely not a position you can trust to just anyone. Hopefully you have the individual with the skills, dedication, organization, curiosity and knowledge to fulfill this demanding role.

Outlined below are 5 Key Indicators that our experienced staff, have observed over decades of experience, and now consider as possible “Red Flags”spa when evaluating a Business Office Manager.

  1. A Cluttered, disorganized office. It is true that some people work well in what looks like chaos to most of us. More often than not you should be concerned when there is paperwork all over the place and you are unable to get a quick, accurate response to questions about current or past due balances. The Business Office, and of course the Business Office Manager need to be organized enough so everyone concerned can easily locate, open and understand all resident files, submitted claims, correspondence and collection notes
  2. Selective Availability – they are seemingly never available when a Resident, Family Member or Staff come to ask a question or for assistance. This type of avoidance is always concerning and should be looked into.
  3. They never take time off. When someone is struggling, or covering up their struggles, they have to stay on top of their mess. They need to be in control of the cash and payment posting to cover their tracks. The vast majority of cases like this are the result of falling behind or incompetence and not theft. The result to you is the same though, your facility is being denied revenue that has been earned.
  4. Excessive delegation of responsibilities to other Business Office staff or continuing complaints from other Department Heads regarding reliability, communications and the ability to work cohesively.
  5. Basic Business Office Practices/Accounting indicators that if observed could represent a Yellow Flag”:
  • The Resident Trust Fund is not balanced.
  • No receipts/backup for withdrawals from Resident Trust Fund. Mis-posting and not posting Beauty and Barber or other specialized private service charges can hide the misappropriation of funds if the proper procedures are not in place or followed.
  • Petty Cash Box Reconciliation is not completed accurately on a monthly basis. Also, not having the appropriate backup receipts and documentation available.
  • Lack of Deposit Slips or Backup documentation to support any Private or Non-Private Pay cash posted.
  • Missing or not easily located Remittance Advices from Medicare/Medicaid Payers, or Explanation of Benefit forms from Commercial Insurance, Managed Care Part A Payers
  • No clear and concise collection notes or backup documentation to support collection efforts related to outstanding balances on the Aging

Finding one, two or even a scattering of these things to be true is not necessarily an indication that you have the wrong Business Office Manager. If you see some of these signs then it is probably time for you to have a serious discussion with her or him. They may be just experiencing burn out and/or need a little extra training, support or coaching to get back on track.

However, if you see a consistent pattern over a period of time or you check these areas and several of them are questionable, you should start asking questions and it may be time to look deeper. Ultimately only you can decide, based on what you discover if it is time to Look for a NEW BOM, retrain the one you have, or stop worrying.

5 Red Flags-Is Your Business Office Costing You Thousands? (Part 1)

The Business Office is critical to the operation and survival of every Skilled Nursing Facility.  The Business Office is usually the least understood of all the major departments, as well as having the lowest level of supervision.  In our two-part “Red Flags” blog series, we will be discussing areas and indicators that can be monitored and reviewed to ensure your Business Office and Business Office Manager are at the top of their game.

No matter how well the rest of a facility functions, the efforts and results posted by the Business Office staff are critical in making sure that the revenue needed for the facility to thrive are received.  As the Administrator or Financial Director, how do you know if your Business Office is not performing as well as you thought, or are being told? How can you check into it before it is too late? What are the “Red Flags” you can keep an eye out for?

There are areas and key indicators of the Business Office Operations that can be monitored and assessed. Based on years upon years of experience in SNF Billing the staff at SNF-Solutions has identified several key Indicators to look for and are happy to share with you our top 10 (5 here and 5 more in part 2).

These “Red Flags”are:

  1. Your A/R Aging increases significantly month after month.  This is usually a clear indication of a lack of timely, accurate billing and/or collections with appropriate attention to follow up and resolve denials or claims issues.
  2. When reviewing you’re A/R Aging Report, you see several consecutive months with nearly identical outstanding amounts for the same payer type.  For example, your outstanding Medicare balance shows essentially the same amount in the 30, 60 and 90-day columns. This usually indicates that the claims for those months have not been submitted.  One of the few universal truths in billing is that you will never get paid for a claim that is never submitted.  A quick example of this may look something like this:
    • 30 days $50,000
    • 60 days $48,000
    • 90 days $53,000
    • 120 days $18,000
    • 150 days $10,000
      • In this case, it might be an indication that 30-90-day old balances have not been submitted, while the 120 and 150-day balances have been billed and at least worked on some.
  3. A quick look at the Cash Receipt Journal report may show issues such as the overuse or misuse of Cash Correction or Cash Adjustments.   You should be alarmed when you see a trend of funds or balances being moved from payer to payer, month to month, or account to account without proper backup.  There should always be supporting documentation related to any type of cash correction or adjustment. You should be able to easily and quickly get the answers to these questions:
    1. Why was this adjusted off?
    2. Were all opportunities to get paid pursued?
  4. Excessive, or escalating, Contractual adjustments and write-offs.  This almost always indicates that there is no, or at least insufficient, effort and research done on any remaining balances after a payment is received.
    1. Do you know if the claim was paid correctly?
    2. Do you really know why you were paid less than you expected?
    3. Why is so much being contracted off?
    4. Should the balance be paid by another entity or the resident?

5. Complaints from Residents or Responsible Parties about statements not being received, payments made not being posted correctly, and account disputes not being resolved in a timely, professional manner.

Remember this is not an all-inclusive list, these are just some hot buttons the Staff at SNF-Solutions have observed over our years of working in Long Term Care.  

If at any point you are unsure of any of these “Red Flag” signs and how they may apply to you, do not hesitate to get an outsider’s perspective from your accountant or a firm like ours.  Just because you are in charge of all that goes on, you don’t have to be, and no one can be, the expert on everything.  Very often the smart play is to get that neutral opinion.

Check in next month for part 2 of “Red Flags” it will be more focused on the Business Office Manager and issues that might indicate you have a possible problem.  Only you can decide what these indicators mean to you and what action is necessary.

Client Stories: 3 Red Flags that show it’s time for your Nursing Facility to get Billing Help

In the belief that knowledge is the key to success, this blog is dedicated to sharing three of our most memorable calls for help. Hopefully you are never in the same situation that some of our most memorable clients found themselves in. They just didn’t know or recognize what was happening around them, but maybe this will help you steer clear of these particular scenarios. These stories may cause you to smile, frown, or even laugh but know that these are true situations (more…)

Congratulations to Mary Jo Wilson!

We are very proud to congratulate our very own Mary Jo Wilson on accepting an amazing invitation to become a member of HCPro’s Long Term Care Biller’s Association Editorial Advisory Board (try saying that 3 times fast).  This honor is in recognition of her involvement in the “Biller’s Talk Listserv Forum”. Way to go Mary Jo!

We are always proud of our amazing team and so happy to see them recognized for their talents and efforts.

Is your facility ready for the new Medicare card?

The Centers for Medicare and Medicaid (CMS) has released new information regarding the April 1, 2018 release of the New Medicare Card for Medicare Eligible Beneficiaries. The New Medicare Card is designed to do away with the old Social Security Number based Health Insurance Claim Number (HICN) and instead will use a new 11-character Medicare Beneficiary Identifier (MBI) number. The MBI will be a unique randomly assigned number.

The new cards will begin to be issued and mailed on April 1, 2018 and all existing cards should be replaced by April 2019.

 

What does this mean to you? What do you need to do?

You, your facility and business office staff need to implement an action plan NOW to ensure that you are ready and will have a smooth transition in April 2018. Your Action Plan at a minimum should include:

 

  • Notifying your residents, families and responsible parties of the change that is coming via:
    1. Including information in your Admissions Packet
    2. News Letter
    3. Posters
    4. Family Meetings
    5. Holding a Facility Social Gathering
  • Assisting your Long-Term Residents in contacting Social Security Administration to verify correct current address (CMS will be using these addresses to mail the new cards).
  • Contacting the Billing Software Company you use (PCC, AHT, Matrix, etc.).
    1. Have they started process to update their system?
    2. Do they have scheduled training sessions available?
    3. Will Update be ready and rolled out on time?
  • Updating Policy and Procedures for Admissions and Business Office Staff.
    1. Insure that they are ready for transition
    2. Ask for new Medicare Card (Get Copies upon admission)
    3. Know how to do Eligibility Checks using new MBI Number
  • Signing up on CMS.gov website to receive the Weekly MLN Connects® News Letter
    1. CMS provides updates regarding the New Medicare Cards through the news letter

CMS has already released that there will be a 21 Month transition period from April 1, 2018 through Dec. 31, 2019. During this transition period:

  • Claims can be billed using either the HICN or new MBI number.
  • Remits will show both the HICN and the new MBI number.
    1. New MBI number will be found in the “Changed HICN” field on the remit
  • If HICN is used to do Eligibility Verification it will not return the New MBI number.

NOTE: Individuals who become eligible for Medicare Benefits on April 1, 2018 and after will be assigned MBI Number Only (no HICNs). This makes it absolutely necessary for you and your facility to:

  • Ask for New Medicare Card upon Admission (make a copy)
  • Have updated billing software in place and working on April 1, 2018

The never-ending cycle of changes to the Medicare System continues and as Providers we need to stay informed, ready to handle the changes. By being preemptive and taking action now you will greatly reduce your headaches and stress prior to the implementation of this change. By actively including your residents or their responsible parties and families and informing them about the changes to come, you assist them in preparing for these changes, and demonstrate how important they are to all involved. All of this preparation will benefit you in filing clean accurate claims, receiving your payments timely and protecting your monthly cash flow. Good Luck! And check back for future Blogs about the….

“NEW MEDICARE CARD”

How Business Office Managers Can Conquer Medicaid Billing

Of the many billing challenges that skilled nursing facilities and business office managers face every day, one of the simplest and yet most difficult, at the same time is Medicaid billing.

What?

Why would anyone say this?

medicaid billing at skilled nursing facilities

Medicaid billing is easy!

In today’s healthcare environment Medicaid has become one of the most dynamically fluid payers a BOM will face. It is state specific and is defined by mandated guidelines that each state proposes and regulates to meet federal requirements and receive federal funds.

In the past, Medicaid billing was simple. Most state Medicaid funds were managed by, claims filed, and payments received through state run agencies and the use of either Turn Around Documents (TAD)s, (yes, we are showing our age and experiences within the SNF/LTC environment) or more recently a state Medicaid website portal.

Changes in the healthcare industry and healthcare reforms have resulted in new regulations regarding Medicaid funds and how they are allocated and reported. As a result, many states are opting to change to a managed Medicaid format. This new format involves the state reaching out to various insurance companies that offer contracts, or implementing a level of care based reimbursement system to provide managed Medicaid services to state approved Medicaid recipients. As states make these transitions and SNFs implement the new face of Medicaid they are very likely to see an increase in the accounts receivable balances for their Medicaid payers.

Depending on the State and which option is implemented, a Managed medicaid system with insurance companies involved (most states can have 3 or more), or a level of care based reimbursement system, the SNF and BOM will face many challenges, such as:

  • Enrollment – Most insurance companies require a SNF to be a participating provider and therefore if not already enrolled a SNF will need to complete the insurance company’s provider enrollment forms. These forms are often located on an insurance company’s website and have to completed and submitted by the SNF prior to being able to receive reimbursement for services provided.
  • Level of Care – Whether insurance companies are involved or not, reimbursement under the managed Medicaid format is often based on level of care which is determined by completion of either PPS assessments or specific state/insurance forms.
  • Medicaid State Eligibility – Some states have changed the actual forms and procedures for applying for and being eligible to receive SNF Medicaid Benefits. This often leads to changes in when and how applications and re-applications are filed.
  • Authorizations – Even though a resident has filed the appropriate applications and is approved for state Medicaid benefits, in the managed Medicaid format an insurance company can, and often does, require a SNF to obtain a prior authorization for Medicaid services. Not only is the initial authorization required but it is often be necessary for the SNF to obtain regular re-authorizations based on the insurance companies predetermined timelines.
  • Insurance/Medicaid Websites – Most insurance companies and states now have their own websites and will require a SNF to submit billing through electronic claims filing processes. This necessitates that the SNF or BOM obtain Login ID’s and learn the various requirements for submitting, tracking, correcting and resolving denied claims through the website. It may be necessary for a SNF to purchase or contract with a company that has the appropriate software to transfer the billing files.
  • Claims Formatting/Payment – Each state or insurance company may and often do require different occurrence codes, value codes and revenue codes to report, track and bill the specific level of care being provided in order to receive payment. This can result in a SNF having to setup new and different specific payer types, charge accounts and GL codes within their current A/R billing software system.

Keeping up with these changes can be overwhelming and frustrating for even the most experienced BOM.

Being able to manage and conquer the face of the new Medicaid a SNF will need to:

  1. Identify the type of managed Medicaid system being used by their state
  2. Identify the changes that impact them based on that system
  3. Modify current policy & procedures or, as necessary, develop new policy and procedures related to managed Medicaid
  4. Possibly hire new staff and/or change job descriptions and duties
  5. Provide training and education

Knowing that a SNF will be facing these challenges, most state Medicaid agencies and insurance companies that provide services for managed Medicaid programs often have training presentations already available. They may also assign facility specific provider representatives who are willing to assist and make the transition to a managed Medicaid system smoother and less stressful.

Our continuously evolving healthcare industry can and has had a tremendous impact on what we, until recently, may have perceived as our easiest payer. A SNF willing to identify, face head on and take the necessary steps, can and will be able to manage and conquer the managed Medicaid system and thereby your Medicaid revenue.

Medicare Secondary Payer – The Lost Opportunity

Your team here at SNF Solutions has noticed a trend of facilities either not filing or having problems with filing and collecting Medicare Secondary Payer (MSP) funds.  These are claims that should only be filed to Medicare after the Primary Insurance Payer, either makes a reduced payment or no payment and the resident is entitled to Medicare A or Medicare B benefits as the Secondary Payer.  Remember, these policies are not HMO or Medicare Advantage Replacement policies, which take the place of Medicare A or Medicare B Benefits.  They are insurance policies that are considered Primary to Medicare benefits and will be listed on Page 16 of the Common Working File (CWF) Benefit Eligibility Screen. Examples of Primary Insurance Payers include Working Aged, ESRD, Disability, VA, Worker’s Comp, Black Lung, Liability, No-Fault, or Medical Insurance related to an Accident Policies.

 

Unfortunately, these Primary Insurance Payers are often not properly identified prior to admission. This hole in the Admissions process results in a Medicare Primary Claim being submitted to Medicare A or Medicare B. The claim will then be rejected (R Status) or returned to provider (T Status) with an error code indicating that there is an open MSP record on the Common Working File (CWF).  The claim error code will inform the Business Office Manager (BOM) of their next steps.  Most often this will require submitting a claim to the Insurance Company first.

 

Once the claim is submitted to the Primary Insurance Company and either a Partial Payment or a Denied Payment is received with the appropriate Explanation of Benefits (EOB) attached, then the BOM should correct the previously denied or returned to provider claim that is on file in DDE and file it as a MSP Claim.  If upon admission of the resident, your BOM read the CWF Eligibility Request, correctly identified the MSP Payer, filed the appropriate primary insurance claim and has received either a Partial Payment or a Denied payment, then they should now submit a MSP Claim.

 

This is where difficulties most often arise in the billing process. Both inexperienced and even an experienced BOM can find it confusing to learn and master. This is because Medicare requires specific condition, occurrence, and or value codes, as well as detailed adjudication (prior payer) information to be included on the claims, either on the UB-04 or in DDE, in very specific formats.

 

Our staff at SNF-Solutions has successfully filed and received payment for clients by submitting clean accurate MSP Claims to Medicare.  We will be happy to assist you and your BOM in doing the same.  SNF-Solutions has developed a training platform which can assist your BOM and facility in collecting this difficult revenue.

 

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5 ways to increase your revenue without adding a single resident

Chances are that you’re leaving revenue on the table. This quick resource guide will help ensure that your office is getting the most from your existing business so you can maximize your revenue without adding a single resident.

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