Jennifer Wormington

In 2006, a final rule was published that requires Medicare to revalidate the enrollment information of all providers every five years. Since that time, very little revalidation has occurred for skilled nursing facilities (SNFs). The Centers for Medicare and Medicaid Services (CMS) recently issued Transmittal 558, requiring each Medicare Administrative Contractor and/or Fiscal Intermediary (MAC/FI) to revalidate the top 50 SNF billers (by revenues billed to Medicare) in each state served by the contractor during the current fiscal year.

As a result, SNF providers have begun to receive letters from Medicare contractors asking them to complete the full Medicare enrollment application (Form CMS 855A) and provide all of the supporting documentation, including required attachments such as the Electronic Funds Transfer (EFT) form for direct deposit of Medicare payments.

Providers have a very short time frame in which to complete and return the requested information. Some MAC/FIs are requiring providers to submit documents within 30 days and others are requiring submission within 60 days from the notification date. In accordance with 42 CFR 424.535, if a provider does not submit the requested CMS 855A form and all attachments by the deadline, their Medicare billing privileges will be revoked and their Medicare program enrollment terminated.

In addition to the top 50 SNFs in each state directly impacted by this transmittal, all SNFs will receive revalidation notices within the next couple of years. Providers should encourage staff members to respond quickly to these notices to avoid any potential adverse impact on operations.

Increased scrutiny of Part A SNF claims

With recent increased post-payment review by MACs and ongoing Recovery Audit Contractor (RAC) audits, SNF providers should be aware that Medicare contractors and other third parties use data analysis to examine provider billing trends that have the most potential to result in Medicare program overpayments. Some key areas of data analysis for SNFs include, but are not limited to:

• High percentage of paid Part A days in ultra high and/or very high rehabilitation RUG categories
• Within these higher categories, a high percentage of paid Part A days in the RUA or RVA RUG levels
• Longer-than-average lengths of stay for Part A patients
• Common use of mental- or behavioral-health-related diagnosis codes on claims for Medicare SNF services

Providers who find utilization patterns consistent with one or more of the above could find their Medicare claims at risk for increased scrutiny. Proper assessment of patients, proper documentation and accurate billing are more critical than ever.

Please contact your BKD advisor if you have further questions or need assistance with the Medicare revalidation process or analysis of Medicare Part A utilization.