The huge complexities in skilled nursing facility billing make it quite daunting. Skilled nursing facility billers must stay updated regarding the changing healthcare regulations and medical codes. Also, intricate documentation requirements make it even more complex. Due to these complexities, Skilled nursing facility billers often make mistakes that lead to claim rejection and delayed reimbursement. As a result, SNFs face revenue loss that affects their overall patient care.
However, Skilled nursing facility billers can simplify these challenges with in-detail billing knowledge and strategic measures. Here, we will share some effective solutions to streamline SNF billing processes, ensuring compliance and optimizing revenue cycles. Let’s get started.
Valuable Tips to Address SNF Billing Challenges
Skilled nursing facility comprises long-term care, rehabilitation, and hospice services. The wide range of services available in these facilities is linked with a variety of medical codes. SNF billers must apply proper codes with modifiers to ensure swift reimbursements. Also, several other challenges make SNF billing pretty complex.
1) Understanding the Diverse Range of Services
Skilled nursing facility offer numerous healthcare services to patients. Some essential services available in Skilled nursing facility are as follows –
- Skilled nursing care
- Rehabilitation services
- Medication management
- Wound and memory care
- Assistance in activities of daily living
- Physical and occupational therapy
Skilled nursing facility billing services must accurately follow the particular billing and coding requirements for the particular service they delivered to the resident. Due to this diverse range of services, Skilled nursing facility billers often tend to commit unfortunate billing errors that result in claim denials. In-depth training is the best way to ensure billing accuracy.
2) Properly Following Regulatory Compliances
Rules and regulations of medical billing are often updated by healthcare authorities like AMA, OIG, and CMS. Recently, CMS implemented a standardized assessment tool, i.e. Minimum Data Set or MDS 3.0. By implementing MDS 3.0, CMS can gather essential data related to residents’ health, functional status, and needs. It helps CMS in public reporting, measuring treatment quality, and to determine reimbursement. Non-compliance can severely affect the functionalities of the Skilled nursing facility. They can face the following consequences –
- Financial penalties, audits, and potential fraud allegations
- Claim denials and delays in reimbursement
- The SNF may face legal action by healthcare authorities
These consequences may affect the day-to-day operations of Skilled nursing facility. Hence, Skilled nursing facility billers must thoroughly observe healthcare news to ensure proper adaptation of regulatory compliances. They must subscribe to newsletters of leading healthcare authorities to ensure they get regulatory updates almost instantly. Moreover, they must thoroughly understand the new federal and state guidelines to eradicate the risk of billing errors and audits.
3) Focus on Accurate Medical Coding
Coding is an essential part of SNF bill preparation and claim submission. Skilled nursing facility bills generally include CPT, HCPCS, ICD-10, and revenue codes with modifiers. Coders must use the proper codes to represent services that are actually provided. About 10% of coding errors happen due to upcoding or downcoding. That results in claim denials or delayed payment. Hence, coders must ensure the highest level of specificity while selecting codes to represent the patient’s condition and services provided.
Moreover, the Balanced Budget Act of 1997 included most SNF services under Medicare Part A. As per this act, the Medicare Administrative Contractor (MAC) acts as a moderator to reimburse SNF claims. For seamless reimbursement, billers must follow Part A MAC guidelines. Skilled nursing facility must train their staff regularly to ensure they use proper codes and modifiers. Also, coders must stay updated on coding guidelines and payer policies. It can prevent common coding errors that lead to claim denials.
4) Submit Proper Documents
Skilled nursing facility must submit detailed documents related to assessments, treatments, and interventions. About 8% to 20% of claims get rejected by insurance payers due to the absence of proper documentation. These are the essential documents, Skilled nursing facility must submit for seamless reimbursements –
- Patient medical history and physical reports
- Doctor’s prescription with a thorough assessment
- Medical records to establish the necessity for skilled care
- Reports and discharge summaries of previous facilities
- Evaluations and progress reports of applied therapies
- ADL logs and nurse aide notes
- Documents to justify each medical code used in Skilled nursing facility bills
Documentation will ensure that the healthcare provided was medically necessary, reasonable, and appropriately coded. Payers will thoroughly check whether the submitted documents justify the rendered treatment and respective costs. Hence, Skilled nursing facility must educate their staff regarding standardized documentation practices. Proper documentation will significantly reduce the rate of denials. This way, Skilled nursing facility can maintain their healthy revenue cycles.
5) Ensuring Prior Authorization
Prior authorization is a complex task for Skilled nursing facility billers. Different insurance payers have separate rule sets for pre-approval. SNFs face an average claim denial rate of 8% to 12% and errors in prior authorization contribute a significant portion of those denials. This results in Skilled nursing facility significant revenue loss or delayed reimbursements.
As per our observation, errors in coding and patient information are the major factors in prior authorization denials. Hence, Skilled nursing facility must thoroughly train their in-house billers regarding the rigorous pre-approval requirements. However, the detailed training can be costly and challenging for in-house staff. Alternatively, Skilled nursing facility can rely on skilled nursing facility billing outsourcing. Third-party billers have the thorough knowledge to secure pre-approval. They ensure Skilled nursing facility get timely reimbursements.
6) Implementing PDPM in SNF Billing
CMS introduced this Patient Driven Payment Model (PDPM) in 2018. It is used to classify patients according to their characteristics, goals, and medical needs. PDPM is applicable in five case-mix adjusted components, such as –
- Physical Therapy (PT)
- Occupational Therapy (OT)
- Speech-Language Pathology (SLP)
- Non-Therapy Ancillary (NTA)
- Nursing services
This patient-driven care model revised the application of ICD-10 codes. It makes Skilled nursing facility billing more challenging and prone to errors. Skilled nursing facility must ensure their billers have accurate and updated knowledge related to PDPM. They must train their staff, so billers have a proper understanding of the implementation of PDPM. Otherwise, they will face claim denials and late payments. It will hamper the Skilled nursing facility revenue cycle.
The Bottom Line:
The increasing complexities make SNF billing pretty challenging and prone to errors. As we can see, Skilled nursing facility face a higher rate of claim denials compared to other medical service providers. To reduce billing errors Skilled nursing facility must put extra effort into training their staff. It will take effort and time, as well as add significant cost to their operational expenses.
The best and most cost-effective solution to reduce billing mistakes is hiring an outsourced skilled nursing facility billing company. These third-party billers have a thorough knowledge of Skilled nursing facility billing and coding. Moreover, they will engage dedicated and expert workers for individual processes. This way, Skilled nursing facility can cut their expenses and ensure top-notch healthcare for improved patient outcomes.
