detailed illustration of a compass with medicare text, eps10 vecYour Medicare Revenue and Collections could be at risk and you might not even know it.

The loyal and intrepid staff here at SNF Solutions has noted a recurring trend during reviews of our clients’ Accounts Receivable.  During our research of the Medicare Part A or Medicare Part B Balances we inevitably see a number of these claims being denied by Medicare for benefit non-coverage due to a patient being enrolled in a Managed Care/HMO/PPO plan that replaces their Medicare Part A or Part B Benefits or vice-a-versa.

How can you prevent this from happening in your facility and be sure that the appropriate payer is being identified and billed in a timely manner?

The answer involves incorporating a simple process or procedure involving Medicare Eligibility and the Common Working File.  Based on the collective experience of our staff we recommend that the Business Office Staff or an assigned staff member complete a Medicare Eligibility Benefit check, commonly called the HIQA/MECCA check, using the Medicare Direct Data Entry (DDE) System, to verify a resident’s current Medicare Eligibility status.  At a minimum the HIQA/MECCA check should be completed for each of the following situations:


  • Upon or prior to admission to verify the prospective residents Medicare or Managed Care/HMO/PPO Eligibility.
  • Upon or prior to readmission to the facility after having a three day/night qualifying stay in a hospital appropriate setting
  • Whenever the Physician, Therapist and Clinical Team determine a resident should begin receiving Part B Therapy Services
  • Monthly on either the last day or first day of the month for all current month residents receiving Medicare Part A or Managed Care/HMO/PPO Benefit Services.


You are probably saying WHAT, WHY??  You most likely understand the basis for the first 3 but why #4??  You might even be thinking this last step is overkill.  Believe us, it’s not. By keeping just one Medicare Replacement claim from going past timely filing, you will more than cover the expense of performing these checks.

In today’s market place it is common practice for the insurance companies who provide these – Medicare Replacement plans to inundate the public with information extolling the benefits of enrolling in their plans vs Medicare.  We have all seen and heard the Television and radio commercials, received the brochures from mass mailings and gone to our favorite big box store or grocery store only to encounter an enrollment booth?

Given these practices and the flood of information, it is not uncommon for spouses or family members to enroll, change plans or disenroll a resident from a plan during any given month and forget to inform the Business Office that they have done so.  Usually, the only way the facility discovers this has happened is when a claim is denied for non-coverage.

IF this change in benefit coverage is not discovered and acted upon in a timely manner it becomes much tougher to get the claim paid. Many of these plans have restrictive billing time limit guidelines and/or require a prior authorization. Not knowing these requirements at the time of the resident’s stay can make it difficult to file corrected claims and get them paid. You may be able to get a retroactive authorization, these are more difficult to obtain the longer you wait and you may be faced with a strong possibility of not being able to collect this revenue.

Have your designated staff perform these HIQA/MECCA Checks based on the scenarios listed above and, most importantly, on a monthly basis to verify the current eligibility status of all Medicare or Managed Care/HMO/PPO residents.  By doing this consistently, you can be assured that you are current and informed of any changes that happened during the previous month.  Remember enrollment/disenrollment changes do not become effective until the 1st of the following month.

Using the information obtained, the Business Office Manager/Staff will be able to take the appropriate actions to ensure that census reflects the correct payer and any needed prior authorizations are obtained.  They can then notify the appropriate facility staff so that nursing notes, physician orders and therapy received are documented accurately and MDS assessments are completed timely.  This will result in revenue being booked correctly allowing for a clean claim to be billed and payment received.


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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.

    For more information, please call 407-977-8878 or contact us. One of our experts will answer all your questions.