Medicare Compliance & Reimbursement

Plus: OIG keeps this matter as an active Work Plan item.

If you’re confused about Medicare consolidated billing rules associated with skilled nursing facilities (SNFs), now is a good time to revisit the payment requirements. Perennial problems with consolidated billing have caused these claims and payments to be under active review by both the feds and the Recovery Audit Contractors (RACs).

Here’s What’s on the OIG’s Radar

Part B payments for ambulance services for SNF patients have remained a thorn in Medicare’s side due to “high error rates and significant overpayments for services subject to SNF consolidated billing,” according to the HHS Office of Inspector General (OIG). Social Security Act sections 1862(a)(18) and 1842(b)(6)(E) specifically outline that “outside suppliers, including ambulance suppliers, must bill and receive payment from the SNF, not Medicare, for services provided to beneficiaries in SNF stays covered under Medicare Part A,” the agency warns.

The agency continues to review the Common Working File (CWF) to spot Part B overpayments that fall under consolidated billing — and nip them in the bud. The OIG added this active item in 2017, and it is still under review.

See the Work Plan item at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000227.asp.

RACs Put SNF Consolidated Billing on Audit List

Background: RACs are independent contractors that data-mine Medicare claims, review them for errors, and collect contingency fees based on the amounts they recover. Because of how they are paid, RACs’ bounty hunter-style payment system encourages them to go after coding and billing errors that are so common and widespread that they will be paid handsomely for discovering (and recovering) overpayments.

Currently, there are five RAC regions of the United States. Generally, Performant Recovery Inc. reviews Region 1 providers in the northeastern U.S. as well as Region 5 (all DME/HHH across the nation), HMS Federal Solutions handles Region 4 in the west, and Cotiviti LLC covers much of the midwestern and southeastern parts of the country, Regions 2 and 3 respectively.

Logistics: There are several SNF consolidated billing issues listed on Performant and Cotiviti websites. The most recent ones involve Ambulatory Surgery Center (ASC) services and therapy services.

Now: With an approval date of April 1, Performant added ASC services that are covered under SNF consolidated billing rules to its audit list while Cotiviti added them on April 2.

“Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions,” Cotiviti reminds. “Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing — Part A MAC Updates for years: 2015, 2016, 2017 and 2018 are overpayments and will be recovered.”

Plus: On Feb. 19, Performant Recovery approved a new audit issue involving SNF consolidated billing for therapies, and on Feb. 20, Cotiviti followed suit.

“Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay,” advises Performant. “They are also subject to the SNF ‘Part B’ consolidated billing requirement for services furnished to SNF Part B residents.”

Here are the links to Performant and Cotiviti RACs’ “audit issues” pages:

• Performant: https://performantrac.com/audit-issues/
• Cotiviti: http://www.cotiviti.com/healthcare/who-we-serve/cms-approved-issues

Important: Since these consolidated billing issues are listed as automated reviews, the RAC will send a notice of the claims that are earmarked for refund. If you provide sufficient documentation to support your claim, the RAC will remove the claim from the list. Any unsupported claims will remain on the list that will be forwarded to the Medicare contractor for pursuit of refunds.

Resource: Go to this CMS map to find your RAC region and the RAC assigned to it: www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-RAC-map-November-2016-clean.pdf.