Industry Insights

Starting on the Right Road to Reimbursement

October 2017
Author:  Jenn Lender

Jenn Lender

Senior Consultant II

Consulting

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

Efficiently collecting monies for services rendered starts prior to admission. A skilled nursing facility (SNF) should have a defined admission process, which can be supplemented with an admission checklist and insurance verification form. The admission checklist facilitates capturing information to treat and bill residents, while the insurance verification form tracks active payor information and eligibility requirements. The responsibility for completing checklists and forms should be outlined in job roles, so personnel can be held accountable for obtaining complete and accurate information.

Having effective processes in place during the admission process can help alert a SNF to potential noncompliance and payor issues before they lead to missed reimbursement. It also helps provide timely communication to residents and responsible parties regarding their payment responsibilities.

Common Areas of Reimbursement Risk

  • Capturing inaccurate resident information, e.g., date of birth, name, address, etc.
  • Admitting residents to the wrong payor
  • Not assessing whether payor coverage requirements are met
  • Not obtaining copies of payor cards
  • Failing to convert Medicaid residents from community Medicaid, when required by the state
  • Not obtaining required authorization
  • Incomplete or unsigned forms, e.g., authorization to treat, physician certifications, etc.

Having accurate information and signed and dated documents also assists the facility in the event of audits, collection efforts, property liens or legal action. In addition to using an admission checklist and insurance verification form, a SNF should have a defined process for storing and maintaining pertinent financial documents for each resident, preferably in an electronic format.

Insurance verification is an important part of reimbursement and should be obtained prior to admission, along with any necessary authorizations. Admission staff should be trained on how to read Medicare eligibility information to determine coverage is active, benefits are available and that no other payors are primary, such as active Medicare Advantage (MA) or Medicare Secondary Payer (MSP) situations.

Asking specific questions prior to admission can help meet payor specifications, such as:

Medicare Part A Admission

  • Has the qualifying hospital stay requirement been met?
  • Are SNF days available, and were days used elsewhere?
  • Are any other payors possibly primary, e.g., hospice, MA, MSP, etc.?
  • Is there Medicaid or supplemental coinsurance coverage?
  • What’s the resident’s financial responsibility?

Insurance Primary or Medicare Advantage Admission

  • Are we contracted with the payor or out of network?
  • Does the payor require a hospital stay?
  • Is preauthorization required?
  • Are subsequent authorizations required, and at what frequency?
  • What’s the payment methodology, i.e., level of care, daily rate, Medicare rates, etc.?
  • Are Medicare Prospective Payment System assessments required?
  • What revenue codes are required for billing?
  • Are there any carveouts for specific medications or treatments?
  • What’s the resident’s financial responsibility?

Medicaid Admissions

  • Does the resident already have Medicaid? If so, what paperwork needs to be sent to switch to nursing home coverage?
  • Has a Medicaid application been sent?
  • What’s the estimated monthly financial responsibility?
  • When will the monthly financial responsibility be billed and when is payment due?

Self-Pay

  • Will the resident qualify for Medicaid? If so, when should an application be sent?
  • How much is daily room and board?
  • What additional charges may be billed outside of room and board?
  • What’s the SNF’s bed-hold policy?
  • When will statements be sent each month and when is payment due?
  • What’s the SNF’s collection policy?

For further clarification, view our sample admission checklist tool and insurance verification form.

For additional information on this and other matters, contact your trusted BKD advisor.

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