There is a new ruling that you need to be aware of.

The DepMedicare Billsartment of Health and Human Services, on Friday, February 12, 2016, released through the Federal Register: Vol. 81, No. 29 their Medicare Program: Reporting and Returning of Overpayments; Final Rule.

This final rule can have a significant impact on facilities that do not have strong management oversight.

Providers interested in reading the entire Federal Register can follow this link Final Ruling.


Why is this important to me?

The Department of Health and Human Services (DHHS) and Centers for Medicare & Medicaid (CMS) are serious about the reporting and returning of overpayments.   Providers have an obligation to establish policy and procedures to ensure accurate, timely billing, and to audit, identify report and return any overpayments received in a timely manner.  The lookback period for these types of claims is now 6 years.


What Can You Do?

Compliance will require a two-pronged approach. You will need to look at your current and past claims, and ensure that you have the process in to ensure your billing is as accurate as you can make it going forward.

For your past claims, start by reviewing your Aging Report to see what is out there. Review those accounts to verify that the balances are indeed credits. You then need to analyze the accounts to determine what is causing the difference so you can identify the processes involved. You will probably find a combination of steps/processes that:

  •  You already have in place but are not being followed
  • You already have in place but need to be modified
  • You need to create and implement new processes

As you close each month’s claims, take a quick look to see if you have everything.  If you have discovered an error in process that results in multiple overpayments, you will need to go back and look at older claims.  The reason is to find the point when the overpayments started.

The best thing you can do to prevent future issues is to stay on top of your claims from admission to discharge. You can help ensure compliance with this ruling by utilizing a number of claim checking and reporting methods.  The suggested list below has powerful processes/methods that our staff at SNF Solutions have seen or used and found beneficial.


Facility Level Regular Preventative Measures:

  1. Daily PPS Meetings –
    1. Participants should include DON, MDS, Therapy and BOM –
    2. A Quick daily review of Therapy, Clinical and ADL information to validate MDS Assessments, especially the need for a COT, SOT or EOT Assessment-
    3. Any resident picked up for Part B Skilled services or ending skilled services needs to be reviewed.
  2. Weekly Medicare Meeting –
    1. Participants should include DON, Nurse Supervisors, Therapy, Social Services, Activities, Dietary, and Restorative –
    2. Review of all current Medicare A and Managed Care A resident charts to ensure accurate documentation, level of care and any possible plan of care updates needed.
  3. End of Month Triple Check Meeting
    1. Participants should include DON, MDS, Therapy, Medical Records and BOM
    2. This needs to be a thorough review of all Medicare and Managed Care UB-04s to ensure timely and accurate billing.


Business Office Level Preventative Measures and Reporting Methods:

  • Medicare Quarterly Credit Balance Report –
    1. The BOM reviews aging monthly
    2. Identify any true Medicare Credits balances that need to be refunded which were not, or could not be handled through the Direct Data Entry System.
  • Weekly A/R Review –
    1. BOM conducts a review of all Medicare and Managed Care accounts weekly
    2. Identify any balances that require adjustment/correction after payment.
  • Daily Medicare Claims Check –
    1. BOM completes a daily review of all Outstanding Medicare Balances in the Direct Data Entry System.
    2. Follows up on:
      1. pending claims
      2. claims returned to provider for correction
      3. rejected claims
      4. denied claims
    3. Makes necessary adjustments and corrections

Periodic Audits:

  1. Monthly Quality Assurance Audits –
    1. Participants should include Administrator, Medical Director, DON, All Department Heads –
    2. Discuss Key Elements commonly reviewed during Annual Survey, Plan of Corrections from prior surveys, Quality Control, etc.…
  2. Peer to Peer Reviews –
    1. Department Heads are periodically assigned to conduct reviews of other departments
    2. This is designed to validate compliance with facility policy and procedures and quality of care.


Now What?

For the present day moving forward, it is imperative that you bill your claims accurately and timely. Just as it is with providing high quality level of care, this takes the cooperation and effort from just about every department.  If you don’t have the processes in place to review each resident throughout the month and each claim before it is submitted, you really need to start now. At the minimum, you need to have a good Triple Check process in place. Help is out there if you need it.

One caution we need to give you is to be thorough. Should you find an overpayment, it appears that CMS expects you to investigate and determine if there are more overpayments on the same issue before quantifying the total and repaying the overage. This means that it is imperative that you are able to and prepared to go back through your claims. You very well may have to look at claims with zero balances on your aging. This would be the case when you find an overpayment due to a rate change on one account, you will need to check all the other similar claims, all the way up to the 6 year take back period limit, where the difference may have been adjusted off of the aging.

DHHS and CMS believe that this ruling provides the needed clarity and consistency to ensure this compliance, only time will tell.  The ruling makes a point of stating;

“that even without this ruling providers and suppliers are subject to the statutory requirements found in Section 1128J (d) of the Act and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability and exclusion from federal health care programs for failure to report and return overpayments.”

So not only do you need to do everything you can to identify and return overpayments, but you should have been doing it anyway prior to this ruling.

Of course there is more to ensuring long term billing success and compliance. you have to have a good team working with good systems and practices. Check out our other blogs for more information.

Your SNF Solutions team



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