Medicare Compliance & Reimbursement

Consult Stark and consolidated billing rules first.

If your physician sees patients in a skilled nursing facility (SNF) or SNF patients come to your office, you are faced with unique billing and reimbursement challenges when it comes to Medicare. Take a look at this case study and see if your billing solutions match up to the experts.

Scenario: Several of my physicians are medical directors of skilled nursing facilities, says Janice Oakley, CCP, RMC, CMM, compliance officer of InterMountain Medical Group in Wilkes-Barre, Penn. They receive a stipend for this from the SNF. Are they allowed to bill Medicare for visits to patients in addition to the stipend? Do we bill, or does the SNF?

The key: There are two parts to billing the types of services this case study discusses. First, you need to get a handle on the Stark regulations that apply. Second, you need to follow SNF consolidated billing rules. Read on to learn more about each important aspect of billing in this situation.

Medical directorships (legitimate ones, that is) usually involve a set of advisory and oversight responsibilities that arent tied to the care and treatment of a single patient, but instead are more of the view from 10,000 feet sort of thing, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC, in Deer Park, Ill. In other words, the physician who is the medical director can admit his own patients to the SNF and can see them in the SNF setting without it having anything to do with the responsibilities he has as the facilitys medical director.

Possible exception: If youre talking about cases where the patient needed to be admitted to the SNF but didnt have a physician who would be managing their SNF care and the medical director was assigned to be the patients SNF attending physician, then it probably would be a good idea for a Stark attorney to review the medical director contract to determine whether there were any Stark issues in the proposed arrangement, Gilhooly says.

Consult an expert: In fact, its a good idea to have a healthcare attorney review any Stark-related questions your practice has. Stark questions really need to be posed to a healthcare attorney with expertise in Stark, Gilhooly warns. The rules are simply too convoluted and the stakes too high to take a chance on getting incomplete information from a laymans opinion on the topic.

In this case: For Oakleys scenario, As far as billing Medicare for the care of a specific patient, no, the SNF would not include that on their facility claim billed to Medicare Part A. Physician professional services are always billed separately on a 1500 to Medicare Part B, Gilhooly says. But if the doctor performs a diagnostic test in addition to the visit, the technical portion of the diagnostic test does fall under the Part A consolidated billing rules.

"The business office manager of these facilities can be helpful in answering questions", says Marilyn Lucus, CPC, contract coder and former practice manager from Arizona. "Dont be afraid to ask. Find out who the medical directors of other facilities are and contact their office or coder."