Medicare Compliance & Reimbursement

Don't let nursing home consolidated billing drain you.

Your staff know which HCPCS codes are included in nursing home consolidated billing. The trouble is, the facility you've billed isn't paying up when it should. In fact, it isn't even taking your calls anymore.

What's a durable medical equipment (DME) supplier to do? Fortunately for those serving nursing home residents in Medicare Part A covered stays, officials from the Centers for Medicare & Medicaid Services (CMS) revisited the question at a recent Skilled Nursing Facility/Long-Term Care Open Door Forum.

Background: Skilled nursing facilities (SNFs) receive a per diem payment from Medicare for residents whose care is covered by Part A. Medicare intends that payment to cover almost all care and services the resident receives during the nursing home stay--including most DME. Unless the consolidated billing rate excludes the item, the SNF--not Medicare--is responsible for paying the DME supplier that has served a resident.

But DME suppliers may soon be able to bring more pressure to bear when a SNF balks at paying a bill. At the recent forum, CMS officials said they continue to hear of situations in which SNFs are refusing to pay outside suppliers that have provided a bundled item subject to consolidated billing.

The remedy: See if the SNF has "mistakenly assumed" it is not responsible for paying for the item, coached a CMS official speaking at the forum. If that doesn't work, and the SNF refuses to take the supplier's calls, the supplier may contact the CMS regional office that serves the state in which the SNF is located.

In the past, CMS has shied away from involving the regional office or other Medicare program officials. The new directive does give suppliers additional leverage in securing payment, experts say. Get Agreements In Writing Suppliers should have a contractual arrangement on file before serving SNF residents, CMS reminds. They should have a "detailed written agreement" with the SNF outlining the payment terms for services and supplies rendered to residents in Medicare Part A stays, suggests CMS.

For more guidance, check out CMS Transmittal R412CP, "Skilled Nursing Facility Consolidated Billing Service Furnished under an 'Arrangement' with an Outside Entity." The transmittal, issued in December 2004 to clarify responsibilities under SNF consolidated billing, is still a great tool for suppliers trying to educate nursing home staffers about their responsibilities, says Virginia Torsch of the American Orthotic & Prosthetic Association in Alexandria, VA. You can view it online at www.cms.hhs.gov/transmittals/downloads/R412CP.pdf.
 
Great resource: If you don't have written agreements with the nursing homes you serve, read through and adapt one of several under-arrangement contracts posted at CMS' "best practices" Web site: www.cms.hhs.gov/snfpps/08_bestpractices.asp.  Sample documents 1 and 2 both give DME suppliers a sound start at spelling out such basics [...]