Eliminating Skilled Nursing Facilities’ (snfs) Medical Billing Complication

Medical billing for Skilled Nursing Facilities has undergone metamorphic changes ever since the Balanced Budget Act of 1997 came into effect 1998. One of the significant requirements under the new legislation is that Skilled Nursing Facilities are not permitted to unbundle services that are administered by contracted healthcare providers. As a result, most of the services provided to Medicare beneficiaries are to be bundled together and billed by SNFs under Prospective Payment System (PPS) in one consolidated claim. The SNF concerned is then responsible to pay for contracted services out of the per diem rate that it earns for caring a Medicare beneficiary.

While this imposition may have helped reduce potential fraud and abuse due to double billing by healthcare providers, SNFs have certainly had a hard time in understanding:

What services are covered under consolidated billing What is billable under Medicare Part A What is billable under Medicare Part B State-specific Medicaid protocols and methodologies for SNFs Medical Billing Commercial health insurance plans and their dynamics

Though most the services offered to a resident under Medicare Part A are allowed to be included in the consolidated billing, certain services deemed costly or requiring specialization must not be appended with the consolidated billing. Generally, physician's professional services; certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services; certain ambulance services, including transporting the beneficiary to the SNF initially, transporting from the SNF at the end of the stay (other than when involving transfer to another SNF), and transporting round-trip during the stay temporarily offsite to receive dialysis or certain types of intensive or emergency outpatient hospital services; erythropoietin for certain dialysis patients; certain chemotherapy drugs; certain chemotherapy administration services; radioisotope services; and customized prosthetic devices are excluded.

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The services that are excluded under Medicare Part A should be billed under Medicare Part B, which allows medically necessary services to be reimbursed under ‘Fee For Service’ (FFS) system. It is possible that SNFs may have not entirely been thorough with these procedures, resulting in billing inefficiencies.

Even as most of the SNFs need to bill Medicare Part A and Part B, there could be SNFs that operate under state-specific Medicaid ambit. And, because each of the 50 states in the U.S. may its own Medicaid program, SNFs should invariably have to bill under their state-specific Medicaid rules and regulations. This regions-specific compliance too may have had a considerable impact on SNFs billing.

Outside the public health insurance plans, SNFs encounter the second largest health insurance providers in commercial health insurance carriers. While CMS has set a uniform standard for reimbursements across the board, commercial plays may still have their own individualistic methods of SNF reimbursement. Thus, SNFs medical billing may have suffered from having to adapt to these multi-payer dynamics.

These SNF-related medical billing concerns necessitate the significance of SNF medical billing specialists that certified and competent to maneuver SNF medical billing executions under Medicare Part A, Part B, state-specific Medicaid programs, and commercial health insurance environment. Medicalbillersandcoders.com has been versatile enough to solve medical billing issues regardless of location, size, or medical disciplines; practices across the 50 states in the U.S. continue to rely on us for remedial and transformational medical billing services. With our nation-wide resource-base adept at multi-component and multi-payer health insurance environment, SNFs should be able to put their medical billing complication to rest.

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Reforming Nursing Facilities Medical Billing Amidst Dwindling Reimbursements

Nursing facilities across the U.S. have somehow endured a series of Medicare/Medicaid cuts thus far, but the latest move by CMS to reduce reimbursement for so-called Medicare “bad debt” – Medicare co-payments not made by beneficiaries or state Medicaid programs – may bring them on the threshold of a major operational crisis. The new legislation has effectively brought down reimbursement rate for bad debts to 65 percent from what used to be 100 percent of unpaid co-payments under dual-eligible beneficiaries, and 70 percent for other Medicare bad debts. With most of the nursing facilities encountering dual-eligibles (Medicare & Medicaid beneficiaries), and federal law allowing Medicaid programs to opt out of making co-payments in most cases, it may be difficult to sustain quality and operationally viable nursing services amidst shrinking Medicare and Medicaid reimbursement rates.

Therefore, it is not unusual for nursing facilities adopting contingency plans to safeguard their operational viability. Amongst several options available to nursing facilities, the following seem to have been deemed strategically more sensible:

Laying off direct service staff Many nursing facilities operators believe that they would be able to off-set the effect of irrevocable bad debts with a reduction in their direct service staff. While they may be able to save considerable overheads, they may also be limiting their ability to sustain service quality. Putting new hiring on hold With limited scope for generating or increasing practice revenues, it may be difficult for nursing facilities operators expand their staff beyond their capacity. That is why most of them are inclined to putting new hiring on hold, and optimize operational efficiency with existing capacity. Here again, they may either be limiting their scope of operation or quality against a likely increase in Medicare or Medicaid patients. Pruning benefits Another plan that may increasingly be adopted is ‘pruning employment-related benefits’ – bonus, increments, promotion, and other amenities. While it may help substantially reduce cost, you could be harming staff’s morale and motivation. Deferring or cancelling expansion plans Reduction in reimbursements may curtail nursing facilities ability to expand with new ventures, and be forced to continue with current capacities despite demand generated by growing Medicare or Medicaid population.

While these plans may be effective to a certain extent, they will certainly be limiting nursing facilities’ ability to sustain quality, motive staff, and look beyond myopic operational strategies. That is why, rather than protective plans, operators would do well to explore alternatives that can keep their facilities responsive to quality and growth demands. Medical Billing is the area which has answers to most of the operational issues. Therefore, operators should look at making their nursing facility medical billing as effective and efficient as possible. Significantly, operators will need to align their billing practices to Medicare/Medicaid’s policy on reimbursing bad debts from disowned co-payments or deductibles.

Medicalbillingandcoders.com remains the most comprehensive source for medical billing solutions, more so for Medicare and Medicaid billing. With a resource base of medical billing experts spread across the 50 states in the U.S., nursing facilities can look forward to instant, effective, and efficient nursing facilities medical billing that can help them sustain quality and grow with evolving demand for nursing facilities.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

The Value of Outsourcing Cardiology Specialty Billing Amidst Changes to Medicare Reimbursement Rates

Any revision in Medicare reimbursement rates will have a direct impact on physicians’ medical billing, and cardiologists are not immune to the effects of frequent changes in Medicare reimbursement rates, announced by The Centers for Medicare and Medicaid Services (CMS) from time to time. While cardiologists or their billers could anticipate the extent of earlier revisions with a fair degree of accuracy, they might not have imagined what they would be encountering in 2013 – as per CMS would have to be prepared for a 2 percent cut over and above the possible 26.5 percent cut to fix Sustainable Growth Rate (SGR) formula. In addition to these general revisions, sweeping changes in rules governing evaluation of coders for certain high percentage cardio-vascular procedures, multiple procedure payment reduction, PQRS and e-prescribing, and value-based modifiers may potentially squeeze cardiologists’ revenues or operational margins.

One of the major changes that may hit cardiologists hard is the creation of new codes and payment levels for certain complex yet frequently encountered procedures. These new evaluation codes could potentially reduce payments from 20 to 27 percent depending on procedures. While representatives are negotiating with CMS for a more rational evaluation system, cardiologists or cardiology specialty billing will continue to be affected till such time when it may be revisited.

Another major concern comes from the CMS’ scheme for implementing a multiple procedure payment reduction to cardiovascular services. This could mean a reduction as high as 25 percent on the technical component of a service relatively less expensive than services performed on the same day. While this may not apply to office visits, most of the cardiovascular diagnostic and therapeutic services that happen to administer multiple services on the same day will certainly have to forgo a major chunk of their reimbursements.

As usual there would be bonus or penalty depending on compliance or non-compliance with PQRS and e-Prescribing – CMS has already made clear that cardiologists will receive 0.5 percent bonus for successfully participation in PQRS, and also be vulnerable to 1.5 percent penalty or reduction for non-compliance PQRS and e-Prescribing standards.

And, value-based modifier that adjusts payment for quality and cost of care could either enhance or decrease the eventual payouts to cardiology practices. While this system is not yet mandatory, you never cardiologists may soon be asked to be part of it under Account Care Organization (ACO) model.

Amidst these sweeping payments changes, cardiologists could be vulnerable to revenue losses, which in turn might jeopardize their sustenance and growth plans. This concern necessitates the significance of cardiology specialty billing that is competent enough to keep cardiologists’ revenue health positive despite the inevitable Medicare cuts.

Medicalbillersandcoders.com has successfully mediated physicians’ medical billing outsourcing decisions in the past; majority of Medical Billing Practices in varied disciplines across the 50 states in the U.S. have made use of our platform to source the right and competent medical billing professionals. Given our equally commendable cardiology-specific billing experience in the past during times of critical medical billing issues, cardiologists should be able to respond instantly and amicably to these Medicare-dictated billing challenges, and keep their practices clinically and operationally efficient.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Complications in Clinical Documentation Leading to Inaccurate Billing Codes

Clinical documentation is a need that threads through the entire lifecycle of an inpatient treatment episode. The clinical documentation specialist checks the documents of a patient before or within 24 to 28 hours of admission to assess various aspects of the patient’s condition, reviews documents every two to three days, during patient stay, to check their progress, accuracy and assign proper diagnosis related group (DRG). Based on assessment, the clinical documentation specialist also sends feedback to the physician who corrects things if necessary before the documentation is used for preparing reimbursement claims.

As is evident, clinical documentation requires extensive documentation of treatment procedures together with their relationship to be used for preparing reimbursement claims. Seen from a reimbursement claim standpoint, anything that’s not documented doesn’t exist and such are coding complexities that the presence or absence of any fact in documentation affects the choice of code later, making it either accurate or inaccurate. This has become more so since the expected implementation of ICD-10-CM.

ICD-10-CM is much more nuanced than ICD-9-CDM. Whereas ICD-9-CDM included 59 codes for diabetes, ICD-10-CM has more than 200 codes for it. Additionally, for diabetes, ICD-10-CM has added a new provision called ‘poorly controlled’ to the already existing provisions under ICD-9-CDM, controlled and uncontrolled. 

Similarly, ICD-10-CM has also increased the number of categories for injuries to cover a larger set of possibilities and arrest the nuances of a wider range of physical specifications of an injury. For example, apart from various details to ascertain the character of an encounter, the ICD-10-CM requires the coder to code the size and depth of an injury. Also, ICD-10-CM contains multiple combination codes to account for relationships between various conditions. After wading through these details, it is not very pleasant to be reminded that the source of these codes is clinical documentation.

Effective clinical documentation requires a grid-like structure underneath the day-to-day healthcare activities involved in an inpatient treatment episode which will arrest medical details, record them and pass them through various phases of the treatment terminating with the discharge of the patient. This process has to be a mix of human effort (to interact with various parties involved) and technology (to record details and facilitate coordination among various specialties – healthcare and otherwise – that interact during the course of a treatment).

MBC’s Revenue Management Consulting can help you with this by performing a thorough analysis of your revenue management cycle and lubricating various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training.

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, has helped medical practices improve their finances by its Outsourced Billing and coding services which involve development of accurate electronic billing, intricate procedure coding, electronic filling of claims and a multi-layered application process - collectively resulting in reduced claim denials and enhanced core-business focus.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.

Tackling Reimbursement Challenges posed by Inpatient Coding with Professional Medical Billing and Coding!

Clinical documentation is a need that threads through the entire lifecycle of an inpatient treatment episode. The clinical documentation specialist checks the documents of a patient before or within 24 to 28 hours of admission to assess various aspects of the patient’s condition, reviews documents every two to three days, during patient stay, to check their progress, accuracy and assign proper diagnosis related group (DRG). Based on assessment, the clinical documentation specialist also sends feedback to the physician who corrects things if necessary before the documentation is used for preparing reimbursement claims.

As is evident, clinical documentation requires extensive documentation of treatment procedures together with their relationship to be used for preparing reimbursement claims. Seen from a reimbursement claim standpoint, anything that’s not documented doesn’t exist and such are coding complexities that the presence or absence of any fact in documentation affects the choice of code later, making it either accurate or inaccurate. This has become more so since the expected implementation of ICD-10-CM.

ICD-10-CM is much more nuanced than ICD-9-CDM. Whereas ICD-9-CDM included 59 codes for diabetes, ICD-10-CM has more than 200 codes for it. Additionally, for diabetes, ICD-10-CM has added a new provision called ‘poorly controlled’ to the already existing provisions under ICD-9-CDM, controlled and uncontrolled. 

Similarly, ICD-10-CM has also increased the number of categories for injuries to cover a larger set of possibilities and arrest the nuances of a wider range of physical specifications of an injury. For example, apart from various details to ascertain the character of an encounter, the ICD-10-CM requires the coder to code the size and depth of an injury. Also, ICD-10-CM contains multiple combination codes to account for relationships between various conditions. After wading through these details, it is not very pleasant to be reminded that the source of these codes is clinical documentation.

Effective clinical documentation requires a grid-like structure underneath the day-to-day healthcare activities involved in an inpatient treatment episode which will arrest medical details, record them and pass them through various phases of the treatment terminating with the discharge of the patient. This process has to be a mix of human effort (to interact with various parties involved) and technology (to record details and facilitate coordination among various specialties – healthcare and otherwise – that interact during the course of a treatment).

MBC’s Revenue Management Consulting can help you with this by performing a thorough analysis of your revenue management cycle and lubricating various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training.

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, has helped medical practices improve their finances by its Outsourced Billing and coding services which involve development of accurate electronic billing, intricate procedure coding, electronic filling of claims and a multi-layered application process - collectively resulting in reduced claim denials and enhanced core-business focus.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.