Overlooked charges add up
With the ongoing concern over limited long-term care resources and dwindling budgets, providers can't afford to overlook opportunities to maximize reimbursement. Nonetheless, reimbursement specialists say many facilities are leaving substantial sums on the table due to a general lack of awareness of billing opportunities and systematic downcoding in the Resource Utilization Group system.
Although the amount of money going uncaptured varies from facility to facility, some say it's not uncommon for the typical provider to sacrifice a couple thousand dollars a month on Medicare Part A, and up to $50,000 a year in Part B.
Based on hundreds of audit reviews, consultant Marc Zimmet of Zimmet Healthcare Service Group, Morganville, NJ, said the average skilled nursing facility loses roughly $7 a day for Part A in billing errors and routine downcoding for the Minimum Data Set. On the Part B side, he said he has seen annual losses climb above the $1 million mark for hospital-based skilled nursing facilities.
"The problem is many providers don't have the manpower to go over their [billing] and make sure they are being consistent and capturing all the opportunities available," Zimmet noted.
Insufficient tracking and monitoring of supplies and services can easily lead an underreporting on UB-92 forms and to omissions or errors of the Minimum Data Set.
"The result is often a RUGs score that is less than appropriate," said Don Frazier, director of implementation for Advanced Answers on Demand Inc., Fort Lauderdale, FL.
Confusion costing providers
Some commonly missed opportunities may be stemming from misinterpretation or confusion of billing requirements. One such area relates to skilled restorative nursing – a service that many facilities are providing, but not claiming due to somewhat ambiguous requirements.
According to Rena Shephard, chair of the American Association of Nurse Assessment Coordinators and president of San Diego-based RRS Healthcare Consulting Services, many providers shy away from restorative nursing billing because of unclear criteria for reimbursement, particularly regarding the number of days required for the service. To offer clarification, the Centers for Medicare & Medicaid Services recently added a piece in the skilled nursing facility section of its online manual that more clearly outlines the requirements. Shephard is hopeful that the clarification will encourage more providers to adequately bill for this service.
To qualify, CMS states that only post-hospital admissions to nursing facilities are covered and the hospital stay must be at least three days. Beyond that, a physician must verify that the resident requires skilled nursing and the services must be provided at least six days a week by a skilled restorative nursing professional (a registered nurse is not considered a skilled professional in this area). Despite the stringent requirements, Shephard said many providers do in fact qualify for reimbursement.
"A restorative nursing program is ideal for residents with low endurance who come into a facility from a hospital but do not require rehabilitative therapy," she explained. "Many facilities are already meeting these requirements and providing these services. It only makes sense that they should be getting paid for them."
Therapies, ancillaries missed
Many providers are also failing to bill for parenteral and enteral nutritional therapy, which is covered under the Part B prosthetic device benefit provision. Facilities can be legitimately reimbursed for the service if the claim contains a written physician order and sufficient medical documentation indicates that PEN therapy is medically necessary. Providers seeking PEN reimbursement must bill to Durable Medical Equipment Regional Carriers and obtain a Durable Medical Equipment, Prosthetic, Orthotics and Supplies number.
"PEN therapy billing makes most sense for facilities that have a sufficient supply volume and a sophisticated charge capture system," said Patricia Dorner, former manager of KPMG LLP Senior Living Services Practices, Harrisburg, PA. "You can bill for PEN if you only have one person a month, but if you have five or six residents, it would certainly be more worthwhile."
The same rules apply to ancillaries, including blood glucose fingerstick tests, tracheostomy supplies, urological and ostomy supplies, wound care dressings,