Medicare Skilled Nursing Facility Billing : How it Works?

Skilled Nursing Facility Billing is a subject apart. Mostly due to the typical complexity around it, a considerable part of billing for the nursing home is about billing treatment of a patient staying in a skilled nursing facility (SNF), and having expert knowledge of Medicare nursing home coverage information. The key uncertainty around nursing home billing arises from the point where Medicare coverage is applied and you cannot ignore the topic as nursing home care doesn’t come cheap. In fact, patients making out-of-pocket payments face a huge burden because of the expensive nature of nursing home care. So, does having a health plan with Medicare solves their problems? Unfortunately not completely, there’s much more to it than answering in a yes or a no.

The fact is patients covered by Medicare healthcare plan don’t get covered for long-term care stays in nursing homes. The grace-saving fact is Medicare does cover expenses for hospital care, doctor visit fees, medical supplies, etc. during the patient’s nursing home stay, thus reducing the burden to an extent.

Having a basic idea about the nursing home general billing guidelines helps prevent costly surprises for patients and also help the practices comprehend the areas of concerns to build case studies for future references:

1. Nursing home services include Bed Hold Days that require Prior Authorization
2. Nursing Home claims can be submitted through the manual/electronic claim systems
3. Nursing Home claims must be submitted within 180 days of the date of service
4. Nursing home facilities can bill for a partial month in case the member (patient) is discharged or expires before the month-end
5. Nursing home bill varies due to factors like:

• Complexity of care
• Level of services
• Room types
• Basic charges
• Ancillary charges

However, if a patient needs a move to a skilled nursing facility within a continuing care retirement community (CCRC), the billing process will be a bit different.

Nursing Home Billing: Reimbursement in an SNF

A skilled nursing facility is a special facility, nursing home, or part of a hospital providing post-hospital care supported by trained care professionals like nurses, physical and occupational therapists, speech pathologists and audiologists, etc. An SNF care is provided in a home-like setting if it’s considered medically necessary. The SNFs are also well equipped with skilled and advanced medical resources to provide a range of assistance to the patients from assisting them with daily simple activities to advanced medical support as and when required.

When is a skilled nursing care required? The following is some typical cases:

1. Fracture Rehabilitation and joint replacements rehabilitation programs
2. Terminal illness care
3. Stroke recovery General wound care
4. Acute medical conditions
5. Post-hospital Interim medical care Respiratory care
6. Parkinson’s care
7. General rehabilitation due to physical weakness
8. Diabetic rehabilitation

General services that are considered for skilled nursing facilities to receive claim payments from Medicare billing include:

1. Semi-private/shared room
2. Meals
3. Skilled nursing care
4. Physical and occupational therapy if required
5. Speech-language pathology services if required
6. Medical social services
7. Medications
8. Medical supplies and equipment used in the facility
9. Transportation in an ambulance to nearest facility provider providing service/s not available at the SNF

10. Dietary counselling

Consolidated Billing – A Quick Overview

In order to reduce the potential fraud and abuse often caused by double billing by healthcare providers, the Prospective Payment System (PPS) has been introduced for SNFs to bill Medicare According to the consolidated billing system; the SNF remains the only entity with Medicare billing capabilities for the services rendered to its residents. Under this billing system, the services provided to a Medicare beneficiary are to be billed together under the PPS as one consolidated healthcare claim. Consolidated billing beside combating the duplicate billing issues, lessens the greater out-of-pocket liability for the beneficiary and help keep the standard of patient’s care from getting compromised due to patient care responsibility getting distributed among several providers.

Skilled nursing facilities billing involves bundled services billed by the SNF to the Part A Medicare Administrative Contractor (MAC) in a consolidated bill. Medicare payment for the majority of services provided to beneficiaries in a skilled facility stay is included in a bundled payment made through the Part A MAC to the SNF.

The basic distinction in Part A and Part B of MAC is:

Part A: Covers room and board charges

Part B: Consists of non-covered SNF stay in which the Part A benefits are exhausted

It’s pretty clear by now that Medicare skilled nursing facility billing is a vast subject. This is the reason why more and more nursing home facilities are turning towards expert medical billers to handle the cases. As the in-house billing executives of the nursing home struggle with the intricacies of nursing home billing and facing rising rejection cases, professional billing services provide cost-effective, efficient, and dedicated services to salvage the situations.

John is an account manager working in a leading DME Billing services provider located in New York.