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Medicare Compliance & Reimbursement

LONG TERM CARE:

These Common PPS Oversights Could Cost Thousands

Published on Tue Jan 25, 2005

 Clear communication is vital to keeping per diem costs in line 

Don't wait to learn this lesson the hard way: Long-term care (LTC) facilities could wind up paying out thousands unnecessarily if even one Part A resident receives the right services in the wrong place.

Skilled nursing facilities have had years to get used to the ins and outs of consolidated billing, but many providers still find themselves saddled with big bills from freestanding health facilities for services they provide to residents in a Part A stay - services that should be excluded from the relatively modest per diem rates Medicare pays the SNF.
 
The hitch: A number of services are excluded from consolidated billing only when they are provided in a hospital or critical access hospital. Send a resident to a freestanding facility for a CAT scan or MRI and the bill for the services becomes the LTC's responsibility - not Medicare Part B's.

SNFs sign provider agreements that stipulate what the consolidated billing per diem includes and excludes - and providers are expected to be savvy about steering residents in the right direction for outside tests or services.

That's not always an easy matter to control, allows Delores Galias of Galias Consulting. Physicians may order services and send a Part A-stay resident directly to a freestanding clinic.

Tip: Communication is essential. For example, if a resident plans to leave with a family member for physician services, request that the resident or his guardian makes clear that the beneficiary is in a Part A SNF stay. Send along documentation listing services that for SNF billing purposes may be provided only in a hospital or Critical Access Hospital (CAH).

See CMS' new Best Practices Web site for sample forms facilities can use to help keep physicians in the loop. One, available at www.cms.hhs.gov/providers/snfpps/bestpractices.asp, lets facilities specify excluded HCPCS codes that could be relevant to a patient's care.

The basics: Make sure all clinical staff are familiar with services that are excluded from consolidated billing when furnished on an outpatient basis by a hospital or CAH.

Great tools: CMS has published a consolidated billing claims processing flow sheet that steers newcomers through the PPS maze at www.cms.hhs.gov/providers/snfpps/flowchart.pdf.

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