SCHAUMBURG, Il. — Skilled nursing providers are leaving millions of reimbursement dollars on the table due to avoidable and costly billing errors — with most coming during the intake and admissions process.
Two leading billing and reimbursement experts presented several findings from a cross-sectional study of long-term care providers between 2019 and 2020 during the LeadingAge Illinois Annual Meeting & Expo last week.
Their study found that, on a monthly basis, claims denials by Medicare Advantage plans averaged from 8% to 10%. On average, providers were able to get that down to 3% to 5% and typically let the rest go after several unsuccessful attempts to appeal the denials.
Findings also showed that 80% of denials actually happen because of the intake and admissions process. Common reasons include information not being gathered correctly or an incorrect health plan being entered into the billing system, explained Steven R. Wermuth, a health policy consultant for Strategic Health Care.
They applied the denial date to a 90-SNF sample of providers in the Ohio Aging Services Network with a net patient revenue of $2 billion.
“Now, let’s do the math. If we’re looking at a 10% claims denial [rate], that’s $200 million in denied claims. If you leave that 5% on the table, it equals $10 million that’s left,” Wermuth said. “That’s a problem because that $10 million is still in the payor’s back pocket for work that you do.”
Wermuth said making sure the intake and admission process is error free is “essential” for providers.”
“When I say error free, it’s making sure that you’re getting all the right [patient] information,” he said.
Key documentation providers need include the patient’s health plan information, hospital discharge plan and health plan provider portal. All of those together can create what Wermuth called an Intake and Admission Report Form, which allows providers to “have all the information in front of you to say if you want to accept or deny that referral.”
Identifying those carve outs where rates can be adjusted in the health plan are really critical, added Elizabeth McLaren, vice president of reimbursement and community-based services for Covenant Living Communities and Services.
“There’s a lot of that nuanced information that every time you get a new contract, you really want to have your admissions or intake person, someone in your clinical department and someone in your billing department getting their heads together [to audit the health plan information],” she said.
That information should be shared together with the clinical department, business office and MDS coordinator. If a referral is accepted, the report can be used to populate the electronic medical record to ensure all of the information is properly entered into the EMR to avoid claims errors.
Providers were also encouraged to use the clearinghouse (which checks to ensure claims get processed correctly) to fix any errors that pop up on the EMR and the Centers for Medicare & Medicaid Services’ Triple Check process. Speakers also said providers must analyze claims data after receiving payment, compare and assess any differences, and keep a record of differences.
“The two things to take away from this, in my opinion: Go back and read your contracts. Medicare is Medicare. It’s the easiest to figure out; it’s the easiest to bill. You know when you’re going to get paid,” McLaren said. “It’s not as easy with managed care, [so] go back and read your contracts because you’re going to identify are there things that you’re making too hard yourself, do you have those potential carve outs and what’s the last time you renegotiated?”
“You’re not only advocating for your residents but you’re advocating for your business and there’s so much you can do with those extra funds if you take the opportunity to ask and be bold,” she concluded.