“Benefit Exhaust” and “No Pay” are you concerned?
If you have worked in Long Term Care or Skilled Nursing Facilities for a long time or are just starting your career, seeing or hearing these two terms could cause you to think OH NO!! What’s happening now? We have noticed a trend with our new clients, very few if any are doing these bills.
Let me set your mind at rest, the Centers for Medicare and Medicaid (CMS) is not going to be stopping your payments or making you fill out more paperwork to keep your license. WAIT, DON’T STOP READING YET, you still need to pay attention.
Per the Medicare Claims Processing Manual, Chapter 6, Section 40.8; ALL Skilled Nursing Facilities are required to file “Benefit Exhaust” and “No Pay” claims for all eligible Medicare Residents who received skilled services. It is through the submission and processing of claims that CMS is able to track and maintain a record of the inpatient services received by all individuals eligible for Medicare Benefits, whether covered and paid by Medicare or not.
In our last Blog “Are your Medicare Revenue and Collections at Risk?” we discussed the Common Working File (CWF) and Eligibility Verification and their impact on your ability to file and collect payment. Well it is through the proper submission of “Benefit Exhaust” and “No Pay” Claims that CMS is able to update the Eligibility and Benefit Stay information maintained in the CWF.
WHAT DO I DO NOW, YOU ASK? It’s very simple, each month you have your Business
Staff file the appropriate “Benefit Exhaust” claims for any/all Medicare Residents who have received skilled services, used the 100 Days of Skilled Nursing Care Benefit and are still receiving skilled services in a Medicare Certified Bed. OR, they will submit a “Partial Benefit Exhaust” Claim when a Medicare Resident stops receiving skilled services during the current month as part of a Medicare Eligible Stay, and remains in a Medicare Certified Bed.
The “No-Pay Claim” is required to be submitted when the resident transfers to a Non-Medicare Certified Bed, or discharges from the facility. The Medicare Claims Processing Manual states that this type of claim could be submitted as one claim and could cover several months by having the From Date be the day after the resident stopped receiving skilled care but remained in a skilled Medicare Certified Bed, and the Thru Date is the date they transferred or discharged. We do not recommend submitting the “No Pay” Claim using this Method!
With the new billing time line requirement for claims to be submitted/accepted within a year of Date of Service, we have seen a trend where claims submitted covering several months are denied for “Untimely Filing”. Based on this trend we recommend submitting the “No Pay” Claim as a Monthly Bill, beginning with the date that the Skilled Services Ended and the resident remained in a Medicare Certified Bed. A “No-Pay” Claim can also be submitted to obtain a Denial in the event an Insurance Company requires it prior to the facility submitting and receiving payment under a plan benefit or policy.
In addition to the “Benefit Exhaust” and “No Pay” Claims needing to be billed Monthly there is one other type of bill that Medicare now requires SNFs to submit. If you accept and bill for Managed Care Replacement Plans CMS requires your facility to submit Managed Care “Informational” Claims to Medicare on a monthly basis. These claims are an exact duplicate of the Managed Care Replacement claims you file. The difference is that they require a Condition Code 04 to be on the claim to indicate that this is an “Informational” claim only for purposes of tracking and updating the use of Skilled Benefits by the resident. Through the submission of these claims CMS is able to track and update the CWF with accurate information regarding a recipients SNF 100 Day Benefit.
Your SNF Solutions team hopes you found this quick discussion both interesting and informative. Please feel free to contact us with any questions or suggestions for future installments. Stay tuned for more!
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