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Who is responsible for billing compliance?

Posted by Gary Winschel on 12/18/13 12:12 PM

The issue:

Who is responsible for billing Medicare and Medicaid correctly? The answer may not be as easy as you think. The business office quickly comes to mind, but what is the responsibility of others? How do we tie together the items and services provided that are medically necessary for each resident and produce an accurate billing that results in timely payments?

How this affects SNFs:

With all the challenges that Skilled Nursing Facilities are faced with today, the last thing needed are fines and penalties. Under the False Claims Act, the Government can impose penalties on anyone that submits a claim that they should know is false. This means that a penalty can be incurred regardless of knowledge that the claim is false. It is the responsibility of the submitter to know that the claim is accurate. Penalties may only be three times the claim amount, plus $11,000, but if false claims are entered repeatedly, the resulting amount could be staggering.

In addition to fines and penalties, inaccurate claims can lead to delayed payments, increasing accounts receivables - or even worse, denied claims resulting in lost revenues. In addition to hard dollars, consider the human resources going into researching and re-filing claims. With quality care being a top priority, do we really need to redirect our resources to address these concerns, or would greater efficiencies be gained by coordinating efforts between departments and their personnel?

What we can do about it:

Procedures should assist staff in recognizing items that lead to false claims and abusive, fraudulent billing practices so they can be avoided. Risk areas associated with billing need to be identified. Remember, medical necessity is the driver - actions taken revolve around this. Sound practices that verify medical documentation is sufficient and the use of therapy is appropriate must be standard.

You hear of sound, comprehensive billing policies and procedures - but outside of the business office personnel, who needs to be involved to make sure things are truly efficient and effective? To ensure correct billing, key information is gathered and recorded by numerous people, and it is critical that clear communication exists between them. This would include Admissions, the DON, Care Plan Coordinator, Therapist, Social Worker and the Biller - to name just a few. These people are responsible in providing correct information that relates specifically to the care that is medically necessary for each resident. The creation of the Care Plan, MDS, and defining the RUGs is part of the process. The Biller may not have direct medical knowledge, but as a team, all the correct data from dates of admission to the correct ICD -9 codes (ones that relate directly to the charges) can be transmitted to avoid a false claim.   

The Billing Office certainly shares in the responsibility in adhering to the False Claims Act and in creating a clean claim. In addition to items mentioned above, here are just a few of the issues that need constant auditing and monitoring:

  • Reconcile amounts billed with cash received
  • Identify and refund overpayments and credit balances
  • Timely research of rejected claims
  • Avoidance of duplicate billing, or including items or services not ordered
  • Billing only at the level of service provided

To be effective in the items mentioned, as well as others, communication between all parties is imperative. Efforts put forth to create or strengthen an effective Compliance Program can also prove to advance the above areas. It will take time and resources, but the results include solidifying procedures within departments and creating cohesiveness within the organization, which will lead to enhanced operations that help prevent unwanted costs from arising.    

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Topics: Billing and Claims Submission, medical necessity

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