Don t forfeit deserved reimbursement: Identify and verify MSP information

April 2009 Vol. 11, No. 4 Don t forfeit deserved reimbursement: Identify and verify MSP information Problems with Medicare Secondary Payer (MSP) claims are common in SNFs, and the majority of these issues stem from flawed insurance identification and verification procedures. Unfortunately, if a resident s insurance information is incorrect, the facility may have to cover the cost of services provided. Establishing a system to ensure the accuracy of insurance information will help your facility receive the reimbursement it deserves. Sometimes, when an individual is covered by an insurer such as an employer s group health plan, disability insurance, or workers compensation, those payers are responsible for the majority of the payment and should be billed before Medicare. In these situations, an MSP claim must be filed. To determine whether there is a payer that is primary to Medicare, facilities are required to identify insurance IN THIS ISSUE p. 4 Triple-check system Decrease your facility s risk of an audit and improve cash flow for facility operations with a well-established triple-check system. p. 6 Common billing errors Protect your facility s bottom line by avoiding these six common billing errors. p. 8 Part B ostomy, urological, and tracheostomy supplies Increase revenue by billing these supplies to your FI or MAC. p. 11 BALTC Q&A Columnist Lee A. Heinbaugh discusses managing accounts receivable and actions to take when dealing with specific payer types in a nursing facility. coverage upon admission using the CMS MSP questionnaire or a comparable form. However, many SNFs complete these forms incorrectly or do not complete them at all, and unfortunately, problems with MSP claims are not usually identified until after the claim is rejected. By the time things get to the billers, it is too late, says Felice Landry, senior billing consultant at Reingruber & Company, PA, in St. Petersburg, FL. Although staff members in charge of the SNF admissions process are usually responsible for gathering insurance information, billers tend to have a better understanding of insurance and are There are major repercussions of not equipped for the completing MSP task. You don t questionnaires or want to give your completing them biller another job, incorrectly. but you do want Felice Landry to look to the SNF business department for guidance, Landry says. SNF billers play a large role in MSP verification and should set up a system with the admissions person to ensure that residents insurance information is accurate, the MSP is identified and verified upon admission, and information is regularly updated. When you assume Facilities are mandated by law to complete an MSP questionnaire upon admission, but not all facilities do this, or do it correctly. Many SNFs have their staff members complete the MSP questionnaire for the resident, especially when dealing with the cognitively impaired, says Missy Tieken, vice president of operations at Consolidated Billing Services, Inc., in Spokane, WA. Information gathered in > continued on p. 2

Page 2 Billing Alert for Long-Term Care April 2009 MSP information < continued from p. 1 this manner is usually inaccurate because the questions were not being asked to the appropriate person. When a facility s staff members complete an MSP form for a resident, they often make assumptions about the resident s insurance coverage, resulting in rejected claims and loss of potential payment. My company does a lot of audits, and when I pick up a financial file and see an MSP questionnaire with every answer checked as no, I am immediately suspicious, Landry says. I think, Did the resident really answer these questions? Or did the facility s staff just assume that, since this person is now residing in a nursing home, none of this was applicable? This is a bad assumption. Editorial Advisory Board Karen Connor Director of Business Operations Landmark Health Solutions Haverhill, MA Joseph Gruber, RPh, CGP, FASCP Independent Consultant Pharmacist Edwardsville, IL Lee A. Heinbaugh President The Heinbaugh Group Lakewood, OH Richard S. Iannessa Senior Vice President of Financial Operations SunBridge Healthcare Corporation Londonderry, NH Elizabeth Malzahn Manager FR&R Healthcare Consulting, Inc. Deerfield, IL Mary H. Marshall, PhD President Management and Planning Services, Inc. Fernandina Beach, FL Billing Alert for Long-Term Care Group Publisher: Emily Sheahan Managing Editor: Adrienne Trivers Associate Editor: MacKenzie Kimball mkimball@hcpro.com Laura McDonnell Corporate Business Manager Merrimack Health Group Haverhill, MA Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC Clinical Services Consultant LTC Systems Instructor HCPro Boot Camps Bella Vista, AR Elise Smith, JD Finance Policy Counsel Finance and Managed Care American Health Care Association Washington, DC Bill Ulrich President Consolidated Billing Services, Inc. Spokane, WA Wayne van Halem, AHFI, CFE Principal WVH Consulting, LLC Atlanta, GA More nursing home residents than ever have primary insurers other than Medicare. The baby boomers are hitting Medicare age, and because of the state of the economy, many people cannot, or choose not to, retire at 65. A lot of people continue working into their late 60s and 70s and may still be covered by their employer s health plan. Some people get remarried when they are older and acquire a new primary payer. Making assumptions about a resident s insurance is never a good idea. Even if SNF staff members are certain there is no primary payer to Medicare, all insurance information must be fact-based and verified. Identification There are major repercussions of not completing MSP questionnaires or completing them incorrectly, Landry says. Many facilities are forfeiting potential revenue because accurate insurance information was not identified. If a SNF bills Medicare when a primary payer is responsible, the claim will get rejected and the facility will have to cover the costs of the services provided. Are you satisfied with your facility s MSP identification process? 76% 24% Yes No Billing Alert for Long-Term Care (ISSN: 1527-0246 [print]; 1937-7452 [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $259/year. Billing Alert for Long-Term Care, P.O. Box 1168, Marblehead, MA 01945. Copyright 2009 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail customerservice@hcpro.com. Visit our Web site at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BALTC. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Source: HCPro reader poll.

April 2009 Billing Alert for Long-Term Care Page 3 Patients and their families are captive audiences upon admission, seemingly making it the ideal time to gather the needed insurance information. However, this may not always be the case. For example, when residents are admitted in the middle of the night, it can be difficult to collect accurate insurance information, Landry says. In these situations, information should be gathered within a short period of time from admission. Talk to the resident or call family members, insurance providers, or the responsible party as soon as possible. If a resident cannot provide his or her insurance details or your billing department cannot gather the necessary information at admission, SNF billers must gather accurate insurance information from the appropriate person as soon as possible. Verification Verifying primary payers at admission is as important as identifying them at admission. Verification is crucial because some insurers have special coverage requirements, such as prior authorization. If a facility does not verify the insurance information, they may not be aware that prior authorization is needed, Tieken says. If a SNF does not get prior authorization when it is required, the claim will be rejected. Facilities cannot bill Medicare or the resident for this because it is a facility error and, therefore, the facility is responsible for payment. It s also important for SNFs to verify the insurance information received from other providers. A lot of times, the information from the hospital is incorrect, and if the facility does not verify the details of insurance coverage, they are just carrying on that bad information, Tieken says. In addition to verifying upon admission, SNFs should verify insurance information when a resident switches to Part B, returns to the facility after a leave of absence, or has a change in payers. Insurance can change at any moment, and residents do not always report those changes to the facility. Facilities should check for new insurance information on a regular basis and make any necessary updates, Landry says. You have to be an investigator, in a sense. Be proactive Checking the Common Working File (CWF) is the best way to determine whether a resident has a primary payer to Medicare. To access the CWF, you must have a password, which can be obtained through your intermediary. In many SNFs, the biller is the only person who regularly accesses the CWF and, therefore, knows how to navigate through the system and obtain insurance information. However, it is good practice for more than one staff member to have access to the CWF because the biller is not always available. To avoid MSP problems, SNF billers must be proactive instead of reactive, Tieken says. SNF billers should look at the CWF prior to or on the day of admission to determine whether there is an insurer primary to Medicare. If there is a primary payer, billers should look up the plan code on the CMS Web site and call the insurance company for verification. Billers should also inquire about the insurer s specific requirements and payment procedures. To ensure proper reimbursements, it is critical that SNFs learn everything they need to know to bill a primary payer on or before admission. Billers must use the CWF, CMS insurance lookup tool, and state inquiry system to verify benefits, Tieken says. If they do these three things and do not assume that every insurer will have the same requirements and payment procedures, facilities will have a lot of success avoiding MSP problems. n Online resources More information regarding Medicare secondary payer (MSP) billing requirements, including CMS version of an MSP questionnaire, can be found in Chapter 3 of the MSP manual at www.cms.hhs.gov/manuals/downloads/ msp105c03.pdf.

Page 4 Billing Alert for Long-Term Care April 2009 The triple-check system: A proactive approach to Medicare compliance Editor s note: This article was written by Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, a clinical services consultant at LTC Systems, a long-term care clinical consultant firm, and an HCPro Boot Camp instructor, and John Ellis, MBA, LNHA, chief operating officer at Reliance Healthcare Management, a long-term care management firm. Reliance and LTC Systems are headquartered in Conway, AR. Each year, the Office of Inspector General (OIG) identifies government programs under the Department of Health and Human Services that are vulnerable to waste and abuse through the submission of erroneous claims. Audits and investigations that were highlighted in a 2006 OIG report found potential Medicare overpayments in the amount of $542 million. This year, the OIG will review a sample of Medicare claims submitted by SNFs to determine the accuracy of coding on resource utilization groups (RUG) claims, appropriateness of Part B services billed during a Part A SNF covered stay, calculation of Medicare days as it relates to no-pay bills, and MDS accuracy, according to the OIG s 2009 Work Plan. In the long-term care industry, these issues are typically addressed through Medicare audit programs, such as the Comprehensive Error Rate Testing, Recovery Audit Contractor, and Medicare Medical Review Programs. A solid triple-check system designed to internally audit claims prior to submission may decrease your facility s chances of being audited and improve cash flow to facility operations. What is the triple-check system? The triple-check system is a claims review process SNF personnel typically conduct in a group meeting. The system can eliminate technical errors such as inaccurate modifiers or incorrect Assessment Reference Date, procedural errors, and documentation errors such as inconsistencies between documentation and the MDS. These problems are usually responsible for inaccurate claim submission. To implement a triple-check system in your facility, begin by identifying the key personnel who contribute to the billing process. Usually, these individuals are any of the following: The business office manager The director of nursing The MDS coordinator The administrator Members of the therapy department Members of the medical records department Members of the central supply department These individuals are responsible for verifying accuracy prior to submitting claims to the fiscal intermediary or Medicare administrative contractor. During triple-check meetings, each person should carefully review claims and supporting documentation, paying close attention to items associated with his or her area of expertise. Developing an in-house checklist with each individual s responsibilities can help the team perform more efficiently (see Responsibilities under the triple-check system on p. 5). Education and monitoring Developing a proactive approach to identify and correct billing issues internally before they become problematic is always good practice. Education and training on billing, coding, and documentation is essential. Monitoring the outcomes of triple-check system audits can pinpoint areas where additional staff training is needed. As with any solid system, continued success is dependent upon disciplined monitoring of the process. n

April 2009 Billing Alert for Long-Term Care Page 5 Responsibilities under the triple-check system One of the best ways to develop and maintain a successful triple-check system is to clearly identify the responsibilities of each individual involved. Creating a tool describing these tasks, such as a checklist, can help focus SNF personnel and ensure that every aspect is covered. The SNF personnel and responsibilities involved in the triple-check process vary depending on whether the claims being reviewed are Medicare Part A or Part B. For example, involvement of the MDS coordinator is essential when Part A claims are reviewed, but would not be necessary when Part B claims are reviewed. Therefore, SNFs should establish separate triple-check systems for Part A and Part B claims. Although the following outline is a comprehensive guide to each individual s responsibilities under the Medicare Part A and Part B triple-check program, a facility may choose to add components based on its needs. Medicare Part A triple-check system The business office manager should verify that: Qualifying stay and days are available per Common Working File The qualifying stay on the UB-04 matches the face sheet and hospital medical records Admit date and service dates are on UB-04 The financial file includes completed and signed Medicare Secondary Payer (MSP) form The business office manager and MDS coordinator should work together to verify that the: Resource Utilization Group on the MDS matches RUG on UB-04 Assessment Reference Dates for each MDS agree with the UB-04 The director of nursing and the medical records staff should work together to verify that: The resident required Medicare skilled intervention through supporting clinical documentation during dates of service Physician certification and recertification signatures and dates are present Physician orders were obtained and implemented The facility director of rehab should verify that: Rehab services are stated on the physician orders Therapy evaluation includes prior level of function Clinical documentation states progress warranting continued skilled intervention The administrator should: Ensure timeliness and effectiveness of the triple-check system Monitor communication effectiveness of facility processes between the interdisciplinary team Medicare Part B triple-check system The business office manager should verify that: Covered service dates on the claim match census covered days The financial file includes completed and signed MSP form The business office manager and facility director of rehab should work together to verify that: The HCPCS code on the claim matches the HCPCS procedure performed per therapy log The appropriate modifier was used The minutes and units on the claim match therapy log Value, revenue, and occurrence codes are accurate The business office manager, MDS coordinator, and facility director of rehabilitation should verify that the: Minutes on the MDS match the therapy log for each therapy discipline Minutes on the MDS and log match the units billed on UB-04 for each therapy discipline The business office manager and director of nursing should work together to verify that: Certification and recertification are signed and dated Orders are documented and signed for all services being billed > continued on p. 6

Page 6 Billing Alert for Long-Term Care April 2009 Responsibilities under the triple-check system < continued from p. 5 The therapy department staff should verify that: Therapy services that are given are stated on physician orders Evaluation includes prior level of function Clinical documentation states progress towards goal The business office manager and medical records staff should work together to verify the: Sequencing of principal diagnosis code on the claim and face sheet Service dates on the claim form The business office manager and central supply staff should work together to verify: The ancillary charges on the claim form The administrator should: Ensure timeliness and effectiveness of the system Source: Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, clinical services consultant, LTC Systems, HCPro Boot Camp instructor; and John Ellis, MBA, LNHA, chief operating officer, Reliance Healthcare Management. Avoid these six common billing errors SNF business departments deal with billing errors on a daily basis, and although some are inevitable, many mistakes can be easily avoided. Reducing preventable mistakes is one of the best ways to protect your facility s bottom line. Before submitting a claim, you should take a few minutes to review the information and focus on trouble spots. Problems in Part A and B claims Whether you are submitting a claim to Medicare Part A or Part B, look out for the following common billing errors: Beneficiary name and Medicare number do not match. Inconsistency between a resident s name and his or her Medicare number has been a common problem for years. You can get a resident s information from many different sources, but if the name and Medicare number do not match up on the claim, it will not go through, says Mary Marshall, PhD, president of Management and Planning Services, Inc., in Fernandina Beach, FL. Get the information off the resident s Medicare card and verify it in the Common Working File. This error usually occurs because the resident s name was incorrectly entered into the facility s system. A simple spelling mistake could cause a claim to be returned, so be sure the name on the claim is exactly as it appears on the resident s Medicare card. Prior claim has not posted for payment. Claims must be submitted in sequential order, so if a prior claim has not posted for payment, hold off on submitting subsequent claims. Often, a biller realizes there is an error on a claim after it has been submitted and immediately submits an adjustment claim, Marshall says. Since the original claim has not yet processed, the adjustment claim will be rejected. Part A errors Part A and Part B each have common billing errors. Catch these Part A mistakes before they occur: Patient status does not match bill type. Billers must ensure that the patient status code is appropriate for the type of bill. For bill types 212 and 213, the patient status code must be 30, indicating the beneficiary is still a resident of the facility. For bill types 211, admit through discharge in the same month claim, and 214, last in a series of claims, the patient status must indicate the beneficiary is no longer a resident of the facility. A few of the patient status codes for bill types 211 and 214 are: 01 Discharge to home 02 Discharge to hospital for inpatient care 20 Expired

April 2009 Billing Alert for Long-Term Care Page 7 If you use a patient status code of 30, which indicates the patient is in the facility, on a 214 bill type, which indicates the patient has left the facility, the claim will not process, Marshall says. Billing more days than allowed by assessment. Under Part A, billers may only bill a certain number of payment days for various MDS assessments, such as fiveday or 14-day assessments. If you bill for more days than the assessment allows, your facility may not receive appropriate reimbursement or the claim may not process, Marshall says. Fortunately, it is easy to spot these mistakes by looking at the HIPPS code, which can be found in form locator 44 on a Part A claim. The first three digits of the HIPPS code indicate the resource utilization group score determined by the assessment. The last two digits represent the assessment indicator code, which identifies the MDS assessment performed. A five-day assessment, represented by a 01 or an 11 assessment indicator code, covers 14 days of payment. Therefore, the corresponding number of service units, found in form locator 46, should not exceed 14, says Marshall. Before submitting a claim, make sure that the number of service units is appropriate for the type of assessment being billed. Part B errors Part B supplies and services are great sources of revenue for a facility, but mistakes on Part B claims can delay reimbursement. Don t let the following Part B billing errors slow your facility s cash flow: Incorrect from and through dates. I see problems with dates a lot, especially when residents leave the facility for a period of time, says Stefanie Knaub, partner at Padden, Guerrini & Associates, PC, in Camp Hill, PA. Let s say a resident receives therapy services for the first two weeks of the month and then goes to the hospital. Some billing systems will generate a claim with the services for the first two weeks, but the from and through dates will span the entire month. Even though the services provided by the SNF do not overlap the hospital stay, the from and through dates do, and Medicare will reject the claim. Make sure that from and through dates on Part B claims only cover actual service dates. Incorrect diagnosis codes for therapy services. SNF billers need to make sure that they capture the correct diagnosis codes for each type of therapy billed. For example, if a resident receives physical therapy [PT], a diagnosis code indicating why the therapy is needed should be included on the claim, Knaub says. However, some billers use the PT diagnosis code for all therapy services provided. Without a diagnosis code specific to the treatment, Medicare will not cover the service. Most of the time, the therapy department provides SNF billers with therapy logs describing the services, start dates, and diagnosis Are you forgetting something? > continued on p. 8 When necessary information is missing from a claim, the claim may be considered unprocessable and returned to the provider. Unprocessable claims must be corrected and resubmitted, ultimately delaying reimbursement. Rather than spend extra time and effort dealing with returned claims, ensure that all necessary information is included in the appropriate form locators (FL) of the UB-04 before submitting a claim. Claims are often returned as unprocessable because the following information is missing: Provider address (FL 1) Type of bill (FL 4) Beneficiary name (FL 8) Beneficiary address (FL 9) Admission date (FL 12) Patient status (FL 17) Occurrence span code and dates (FL 35 36) HCPCS codes (FL 44) National Provider Identifier number (FL 56) Principal diagnosis code (FL 67) Source: Wisconsin Physicians Service Insurance Corporation, Noridian Administrative Systems, and CMS.

Page 8 Billing Alert for Long-Term Care April 2009 Billing errors < continued from p. 7 codes. To ensure accuracy, SNF billers should always compare the charges and codes on the claim to the therapy log. Missing KX modifier. When Part B therapy services provided to a resident exceed the therapy cap amounts, which are $1,840 for PT and speech-language pathology (SLP) combined and $1,840 for occupational therapy (OT), providers can request an exception by appending the KX modifier to the HCPCS codes for that modality. For claims that include both PT and SLP, you would add the KX modifier to all the PT and SLP codes on the claim when the therapy cap is exceeded, regardless of which discipline exceeded the limit, Marshall says. If OT is also included on this claim and did not exceed the OT cap, you would not have to append any KX modifiers to the OT codes. Remember, the use of the KX modifier does not guarantee payment. Services exceeding the therapy cap are subject to medical review. Missing 59 modifier. Medicare s National Correct Coding Initiative (NCCI) edits deny payment for certain services that should not be billed together on the same day. However, under certain circumstances, a provider can bill these services on the same day if they were done on separate parts of the body or in distinct sessions. In these cases, the 59 modifier must be added to the secondary, additional, or lesser service in the code pair to bypass the NCCI edits. There must be documentation to support the need for both codes, particularly the secondary code. Unfortunately, people are still struggling with the 59 modifier, even though it has been around for a couple of years, Knaub says. If the 59 modifier is omitted, providers will not be reimbursed for the secondary service. Facilities do not receive an error code when 59 modifiers are missing; they simply don t receive payment. Without notification, providers may be unaware that payment was denied for a portion of the claim. You need to check your facility s accounts receivable every month to make sure all items on the claim were paid for, Marshall says. If you billed for ten therapy services on a claim and only received payment for five, chances are the other five needed a 59 modifier. n Ostomy, urological, and tracheostomy supplies: An easier approach to Part B billing Editor s note: The following is the third article in a four-part series about billing Medicare Part B for supplies. Stay tuned for next month s article, which will cover billing for wound care supplies. Similar to Part A services, facilities can bill Part B ostomy, urological, and tracheostomy supplies directly to their fiscal intermediary (FI) or Medicare administrative contractor (MAC). Since SNF business offices are familiar with this process, billing for these supplies is not as labor-intensive and time-consuming as billing for other Part B items. Ultimately, billing Part B ostomy, urological, and tracheostomy supplies can generate revenue for a SNF without the headaches that can accompany other supply billing procedures. Familiar billing process Although a facility can bill Part B ostomy, urological, and tracheostomy supplies directly to their FI or MAC using the UB-04, the Part B billing requirements differ from those of Part A.

April 2009 Billing Alert for Long-Term Care Page 9 Part B requires line-item date of service billing. This means each supply, accompanied by the corresponding HCPCS code and service date, must have its own line on the bill. Depending on the billing system used, line-item date of service billing can be labor-intensive. However, it does not require any more time or effort than a Part B therapy claim, says Theresa Lang, RN, BSN, RAC-C, WCC, vice president of clinical consulting at Specialized Medical Services, Inc., in Milwaukee. Since ostomy, urological, and tracheostomy supplies are considered prosthetic or orthotic devices, revenue code 274 must be included for each item on the claim. Although the requirements to bill Part B for these supplies may be different than the typical Part A process, SNF billers are familiar with the UB-04, says Elizabeth Malzahn, manager at FR&R Healthcare Consulting, Inc., in Deerfield, IL. They do not have to deal with the challenge of learning new forms and working with a new claims processing contractor. Medical necessity and coverage requirements Billing for ostomy, urological, and tracheostomy supplies involves a wide variety of items. For example, covered ostomy supplies typically include ostomy faceplates, pouches, adhesives, and barriers. Part B billable urological supplies include insertion trays, catheters, and collection devices. Since Medicare only covers certain items associated with tracheostomy care provided to SNF residents, facilities should only bill for a limited number of tracheostomy supplies, such as care kits. But before submitting Part B claims for these supplies, SNF billers must ensure that the criteria for medical necessity and coverage requirements are met. Medicare Part B covers: Ostomy supplies provided to a SNF resident with a surgically created opening to remove waste, such as urine or fecal matter, from the body. Urological supplies provided to a resident with permanent urinary incontinence or permanent urinary retention. Tracheostomy care kits provided to a SNF resident after a surgical tracheostomy. The tracheostomy must be expected to remain open for a minimum of three months. Supplies not essential to these processes are considered medically unnecessary and, therefore, not covered by Medicare. Although CMS national coverage determinations establish basic coverage criteria for services and supplies, > continued on p. 10 Commonly used HCPCS codes When submitting Part B claims for ostomy, urological, and tracheostomy supplies, SNFs will bill for a wide variety of items. Listed below are HCPCS codes for some commonly used ostomy, urological, and tracheostomy supplies. HCPCS Description Insertion tray without drainage bag and without catheter (accessories only) A4310 Irrigation tray with bulb or piston syringe, A4320 any purpose Male external catheter with integral collection chamber, any type, each A4326 Female external urinary collection device, A4327 metal cup, each Indwelling catheter, Foley type, two-way latex with coating (teflon, silicone, silicone elas- A4338 tomer, or hydrophilic, etc.) A4361 Ostomy faceplate, each A4625 Tracheostomy care kit for new tracheostomy Tracheostomy care kit for established A4629 tracheostomy For a complete list of ostomy, urological, and tracheostomy HCPCS codes, visit www.cms.hhs.gov/ MedHCPCSGenInfo. Source: CMS.

Page 10 Billing Alert for Long-Term Care April 2009 An easier approach < continued from p. 9 many FIs and MACs have created more detailed requirements, known as local coverage determinations (LCD). LCDs, which can be found on contractors Web sites, often require additional documentation to support the medical necessity of a service or supply. If a biller is aware of this requirement, he or she can inform the clinical staff about what is needed and, ultimately, avoid problems before they occur. Detailed documentation All ostomy, urological, and tracheostomy supplies require a physician s order, which should be as specific as possible. The physician s order must specify the type and quantity of supplies. Any change in supply type or increase in supplies requires a new order. You must have clinical supporting documentation for each supply. I have my clients write very specific physician s orders. This way, when the nurse initials off that he or she did a treatment, it is sufficient information to be able to bill from, Lang says. Before submitting a claim, check that all diagnosis codes are appropriate for the services being billed. If you have any questions about diagnosis codes, documentation, or the physician s orders, seek assistance from the clinical staff. Given the detailed documentation and facilitywide cooperation needed, billing your FI or MAC for Part B ostomy, urological, and tracheostomy supplies is truly a team effort. The Medicare Improvements for Patients and Providers Act of 2008 requires that all DMEPOS suppliers be accredited by September 30. However, the accreditation process can be expensive and lengthy, taking an average of 9 12 months. To meet the deadline, enrolled DMEPOS suppliers were required to submit accreditation applications by January 31. Suppliers who do not meet the September deadline will have their DMEPOS supplier number and billing privileges revoked October 1. If a SNF has a DMEPOS supplier number, which is different from a Medicare provider number, it must be accredited in order to maintain its supplier status. Unfortunately, there are many conflicting interpretations of the DMEPOS accreditation requirement, and at presstime, it remained unclear as to how facilities billing their FI or MAC for Part B supplies will be affected by this regulation. We will be following up with CMS and will keep you updated on any new information. n Illustration by David Harbaugh What accreditation requirement? SNFs are required to bill certain Part B supplies, such as parenteral and enteral nutrition, to their durable medical equipment MAC. To do so, the facility must first obtain a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier number. As a supplier, the facility is required to meet all of the DMEPOS supplier requirements, which in 2009 include accreditation. I m a RAC survivor... but enough about me.

April 2009 Billing Alert for Long-Term Care Page 11 BALTC Q&A Editor s note: BALTC Q&A was written by Lee A. Heinbaugh, president of The Heinbaugh Group, a long-term care consulting company in Lakewood, OH. To submit a question for upcoming issues, e-mail Associate Editor MacKenzie Kimball at mkimball@hcpro.com. I am the administrator at a long-term care facility, and the owners have asked me to take a more active role in the financial aspects of the business. As part of this new role, I am to oversee the billing department and assist in the management of the accounts receivable. I am new to long-term care and do not have a lot of experience with the payers in a nursing facility. I was hoping you could give me some advice as to how to approach the accounts receivable from a management perspective. Managing the accounts receivable is essential for a nursing facility to survive our current economic environment. The first step for you is to break down the different accounts by pay type. Each pay type has its own set of issues and frequency for payment. Below, I have listed the main payer types in a nursing facility and some necessary actions that should be taken based on the specific payer: Private Identify who is responsible for making payments and, if it is someone other than the resident, get copies of the power of attorney (POA) document. Review terms of payment with the resident or legal representative to be sure he or she has a complete understanding of his or her financial responsibility. Monitor the account and, when the resident runs out of funds, be sure the family applies for Medicaid in a timely fashion. Inform the resident or responsible party about the misappropriate spenddown of private funds that could deem the resident ineligible for Medicaid. Be sure that your billing staff is following these procedures and has a good collection policy. This should include phone calls, letters, or direct contact with the person responsible for the resident s finances to ensure that payments are made on time. Medicaid pending Continue to bill the resident or family privately while the Medicaid application is pending. Monitor the status of pending applications and know why an application is being delayed. If necessary, your facility can intervene to prevent the case from being closed. Collect the estimated patient liability amount to be sure the funds are not spent inappropriately. Uncollected patient liability payments can become bad debts for a nursing facility. Explain the resident s or responsible individual s liability to the facility for the social security and pension payments. The facility should maintain a list of pending Medicaid applications and include information necessary to the finalization of the application, such as the date it was filed. Medicaid Medicaid systems are usually billed in a monthly cycle. In most instances, there should not be a balance unpaid for any month other than the current month unless your facility uses the Medicaid pay type for pending accounts. If there are outstanding balances, your billing staff should know why they are outstanding and work to resolve the issue. Medicare Medicare is billed on a monthly cycle. Medicare will make payment for clean claims within 14 days Questions? Comments? Ideas? Contact Associate Editor MacKenzie Kimball > continued on p. 12 Telephone 781/639-1872, Ext. 3265 E-mail mkimball@hcpro.com

Page 12 Billing Alert for Long-Term Care April 2009 BALTC Q&A < continued from p. 11 of receipt. The Medicare online system makes it very simple to monitor claims and make corrections. The most common issue for the delay in payment of a Medicare claim is when there is a Medicare Secondary Payer situation. Medicare issues a monitoring tool, known as the 210 report, each Monday that will show the transition of all Medicare claims from receipt to payment or initial denial. Medicare coinsurance Verify the coinsurance payer. If paying privately for the coinsurance, be sure the resident or POA is aware of the $133.50 amount due from day 21 100. If insurance is paying for the coinsurance, confirm coverage and payment terms. If the insurance is only paying a portion of the amount due, be sure to notify the resident or POA of the amount he or she will be responsible for paying. The billing staff must confirm the coinsurance amount is correct when Medicare makes its payment and make corrections in a timely fashion to ensure that the accounts receivable are accurate. When Medicare primary payment is received, the biller should review the payment file to determine whether the coinsurance has crossed over to the appropriate coinsurance payer. If not, the electronic or paper coinsurance claim should be prepared as soon as the primary payment is received. Coinsurance is the number one bad debt write-off for most nursing facilities. My rule is: If the secondary payer has not paid within 30 days of the primary payment, contact the payer to confirm crossover and submit the electronic or paper claim as appropriate. Managed care and commercial insurance coverage Confirm coverage and payment terms. Notify the resident of his or her responsibility for copayments, should they exist. Residents and POAs are often unaware of the copayment due with the HMO policy. Identifying the copayment amount should be done as soon as possible. Don t allow your facility to incur a bad debt because the copayment amount was not identified up front and communicated to the resident or POA. The most important steps you can take to be sure you are collecting your accounts receivable are to review the aging report on a regular basis and implement procedures for reporting problem accounts and late payments. The earlier the facility identifies payment issues, the faster the issues can be resolved. n BALTC Subscriber Services Coupon Start my subscription to BALTC immediately. Options No. of issues Cost Shipping Total Electronic 12 issues $259 (BALTCE) N/A Print & Electronic 12 issues of each $259 (BALTCPE) $24.00 Order online at www.hcmarketplace.com. Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at 888/209-6554. *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax E-mail address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of BALTC.) Mail to: HCPro, P.O. Box 1168, Marblehead, MA 01945 Tel: 800/650-6787 Fax: 800/639-8511 E-mail: customerservice@hcpro.com Web: www.hcmarketplace.com