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Tag Archives: Medicare

Bolster billing compliance: Implement a Medicare Part A triple-check process

Bolster billing compliance: Implement a Medicare Part A triple-check process

Medicare billing is a domain rife with payer offshoots and evolving regulations that can be difficult to navigate without a strategy to weather claim scrutiny and withstand the gaze of CMS’ various auditing contractors.

Enter the triple-check process, a time-tested internal auditing strategy used by proactive long-term care providers to facilitate billing accuracy and compliance the first time a UB-04 claim form is submitted. As its name suggests, triple check is a layered verification process that involves staff members from billing, nursing, and therapy departments?the three core disciplines required to submit a clean claim. But this sturdy foundation is also pliable, allowing a facility to easily adapt the procedure to the various types of claims it files.

Read on for an expert iteration of the triple-check process, which is modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC. This specific triple-check procedure is designed to mobilize key staff to ensure accuracy and timely submission of Part A claims.



Each month, the SNF will collect all Medicare Part A billing information ready for submission and enlist the following individuals to carry out their designated roles in verifying the accuracy of these items: administrator, director of nursing, MDS coordinator, facility rehab director or designee, business office manager, medical records personnel, and central supply staff.

The following is a breakdown of each of these staff members’ responsibilities in the triple-check process:

Business office manager and medical records personnel

  • Verify that the qualifying stay information recorded on the UB-04 aligns with that on the medical records face sheet.


Business office manager

  • Verify that each resident has benefit days available in the HIPAA Eligibility Transaction System.
  • Verify the admit date on the UB-04 aligns with the date in the manual census log.
  • Verify covered service dates listed on the UB-04 align with those in the Medicare and manual census logs.
  • Verify that a resident’s financial file contains a signed and completed Medicare Secondary Payer form whenever applicable.


Business office manager and MDS coordinator

  • Verify that ADLs are correct and are supported by documentation. Confirm that staff have coded all other contributory items (e.g., mood, IVs).
  • Verify that ARDs on each MDS align with the occurrence dates found at form locators (FL) 31?34 on the UB-04.
  • Verify that the RUG level listed on each MDS aligns with that found at FL 44 on the UB-04.
  • Verify that the assessment type for each MDS aligns with the modifier found at FL 44 on the UB-04.
  • Verify that the number of accommodation units listed on the UB-04 aligns with the assessment type for each MDS. Verify that the total number of accommodation units aligns with corresponding covered service dates.


Facility rehab director, MDS coordinator, and business office manager

  • Verify that physical therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes documented in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that each principal diagnosis is accurate, that all secondary diagnoses support skilled care, and that every ICD-9 code corresponds to an appropriate diagnosis.
  • Verify that occupational therapy minutes recorded on the daily treatment grid align with those in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that speech therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.


DON and medical records personnel

  • Verify each resident’s need for Medicare skilled intervention by reviewing supporting clinical documentation that corresponds with the dates of service listed in the manual census log.
  • Verify that each (re)certification form has been completed and signed by the appropriate physician.
  • Verify that each physician order has been obtained and implemented.
  • Verify that each chart reflects appropriate charting guidelines. Confirm that charting has been completed at least once in every 24-hour period, relates to skilled service provided, and supports therapy.


Facility rehab director

  • Verify that physician orders include rehabilitation.
  • Verify that each evaluation notes the prior level of function.
  • Verify that clinical documentation contains a progress note establishing the need for continued skilled intervention.



  • Chair the triple-check meeting (detailed below), and ensure that the entire process is completed by appropriate staff each month before Medicare claims are submitted. Participation in the triple check will allow the administrator to monitor the effectiveness of key operational processes carried out by the facility’s ­interdisciplinary team (IDT) on an ongoing basis.

Triple-check meeting and audit tool

Each of the SNF’s triple-check participants should complete their respective duties prior to the Medicare triple-check meeting, which will be held monthly before the SNF bills for a given batch of services. In other words, the meeting is not an occasion for staff to complete their initial claim component(s). Instead, it’s a chance for IDT members to cross-check the work of their colleagues by verifying the accuracy of claim items that others have completed, thereby ensuring each element has been studied by multiple sets of eyes.

The triple-check meeting will also serve as the platform for the SNF’s business office manager to document the completion of each integral item on a billing claim using the triple-check audit tool, an internal checklist-type document that will be included in every month-end closing report.

Using this audit tool, the manager will denote items verified as correct during the triple-check meeting with an "X." He or she will mark items identified as incorrect with an "O" and, in the remarks section of the document, record the steps the team will take to obtain the correct information. Items initially found to be incorrect but rectified during the meeting should still be marked with an "O" to better track any practice patterns that could lead to billing slipups and inform future training activities.

The business office manager will call for any claim found to have errors during the triple-check meeting to be put on hold until it is amended. Once staff have made necessary revisions, the manager will indicate these correction(s) and the corresponding date(s) in the remarks section of the audit tool. He or she will then contact a corporate entity to review the changes and ultimately grant approval to submit the claim. – Billing Alert for Long-Term Care

Medicare myths

Medicare myths

Editor’s note: This article is excerpted from the book Long-Term Care Skilled Services: How to Document for Proper Medicare Reimbursement, by Elizabeth Malzahn-McLaren.


Throughout my years of educating providers on the inner workings of the Medicare program, whether it was a boot camp class for newcomers or a refresher course for those in the business for years, there are always instances where I am able to "myth-bust" Medicare. With any program, especially one that has been in existence for 60 years, there are bound to be some myths out there about how the program works.


Myth #1: A psychiatric resident will not qualify for Medicare Part A skilled services.

Although most psychiatric services will not qualify as Medicare Part A skilled services, there are some instances when a resident will qualify coming straight from the hospital, at least for a short period of time.

First you need to determine if the stay in the psychiatric hospital meets the three-day qualifying hospital requirement. If it does, the next area to review is whether the care meets the requirements for skilled services under Medicare Part A.

The resident may need to have his or her medications adjusted; there also can be potential for an adverse drug reaction if medications were changed. In addition, depending on the time spent in the hospital, there may have been some deterioration and the resident may have therapy orders upon discharge from the hospital. Other areas to review include hearing, speech, and vision (Section B of the Minimum Data Set [MDS]); ­cognitive patterns (Section C); mood (Section D); behavior (Section E); functional status (Section G); and medications (Section N) … just to name a few!


Myth #2: You can cover a resident for the first five days to observe and assess his or her condition.

The Centers for Medicare & Medicaid Services (CMS) provides no time frame of minimum or maximum time covered; however, there is the ability to use administrative presumption of coverage. Remember, though, that the use of the administrative presumption is reserved only for residents being directly admitted from a three-day qualifying hospital stay. In addition, this administrative presumption only covers up to and including the assessment reference date (ARD), if no skilled need is identified on the initial admission/readmission MDS. The regulation indicates that a resident can be skilled "until the condition of the patient is stabilized." Typically, skilled care for observation and assessment lasts for a few weeks or less.


Myth #3: A new diagnosis triggers a new benefit period.

This is one of the most dangerous Medicare myths out there. It can impact not only resident care, but also customer service, and it can have a significant financial impact as well. The only way a resident can earn a new 100-day benefit period under SNF Medicare Part A is to complete a 60-day period of wellness. The calculation for earning a new benefit period is based on two criteria:

  • Determining when skilled services ended
  • Counting days

There is no magic formula to earning a new benefit period. Let us review an example to illustrate how the calculation should work.

A resident completed a 100-day Medicare benefit period on December 31. The resident remained skilled under Medicare Part B, receiving therapy services until January 31. Beginning February 1, the resident was no longer at a skilled level of care. Based on the counting of 60 days, the resident would be eligible for a new benefit period on April 2 (assuming 28 days in February). However, we need to review each day between February 1 and April 2 to make sure none of the following occurred:

  • Did the resident receive any services that would qualify the resident under a Medicare skilled level of care while in the SNF during that time period? For example, was the resident picked back up under a Medicare Part B plan of care that met the skilled level of care requirements?
  • Did the resident have any inpatient admissions to the hospital during that time period?


If the answer to either of these questions is yes, then the resident did not earn a new 100-day benefit period based on either the provision of skilled services or failure to meet the 60-day period of wellness requirement.

There is one small wrinkle in this calculation of benefit periods. If a resident leaves the SNF and continues to receive a skilled service while residing at home, for example, this would not impact the benefit period. When reviewing skilled services received, Medicare is only looking at skilled services received while in a SNF or as an inpatient of a hospital. Skilled services rendered to a beneficiary in the home setting do not impact the Medicare Part A SNF benefit period calculation.


Myth #4: All residents who are receiving tube feeding are always skilled and always will be skilled.

This statement is both true and false. The caveat lies with the level of calories and fluid the resident is taking in through the tube. Residents who meet the 26%?50% of calories and 501 cc of fluid per day via the feeding tube, or residents who receive 51% or more of calories via the feeding tube will automatically qualify for ­Medicare Part A benefits in a SNF. Additionally, they are required to continue on Medicare to use a full 100-day benefit period until they drop below such levels on an MDS. These levels will also continue that spell of illness and prevent the resident from attaining the 60-day period of wellness to qualify for a new 100-day benefit period.

Residents who meet the caloric and fluid requirements of 26%?50% of caloric intake and 501 cc of fluid daily via the tube or residents who receive 51% of more of caloric intake from the tube will remain at a skilled level of care for a full 100 days, as long as they remain at those levels. In addition, the resident will not qualify for a new 100-day benefit period unless he or she:

  • Drops below the calorie and fluid levels previously identified for 60 consecutive days without any other skilled service in the SNF or inpatient hospital stay
  • Remains at those calorie and fluid levels identified previously but discharges to home with skilled services being provided in the home for 60 consecutive days


Myth #5: As long as there is an inpatient hospital stay or Medicare Part A SNF stay within the last 30 days, we can pick the resident back up on Medicare Part A.

Although this is partly true, the most important criteria to using the 30-day window is relating the reason for coverage back to the original hospitalization or a condition that arose during treatment. If the reason to pick the resident back up under Medicare Part A is completely unrelated to the original hospitalization or subsequent SNF stay, the criteria outlined in the regulation regarding the 30-day transfer rules are not met, and the resident should not be put back on Medicare Part A.


Myth #6: A resident on Medicare Part A in a SNF can never leave the SNF for an overnight leave of absence.

Often, a resident is unable to leave the SNF due to the complexity of the services being rendered in the SNF. That said, a couple of items need to be reviewed before determining if an overnight leave of absence (LOA) is feasible:

  • Can the resident safely be away from the SNF, and can the family or responsible party be taught to safely meet the resident’s needs while out of the SNF?
  • Are the absences infrequent in nature and not for prolonged periods of time?


Obviously, the first question is important to make sure the resident can be properly cared for during the LOA. It is always necessary to consult with the resident’s physician to notify him or her of the LOA request and get some feedback from the physician’s point of view on whether the LOA is feasible. The second question relates more to being sure that the practical matter criteria also discussed in Chapter 3 is being met. If a resident is able to leave the SNF on a weekly basis for an overnight visit, or if the resident leaves for prolonged periods of time three times per week to attend an off-site bingo game, for example, it is doubtful that the practical matter criterion is being met. Remember, one of the four criteria related to meeting the skilled services requirement in a SNF is the practical matter criterion in Section 30.7 of the Medicare Benefit Policy Manual (Pub. 100-02):

As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF (see §30.7).


That said, although a resident may safely be able to go on LOAs frequently or for prolonged periods of time, the question becomes: Is the SNF the most appropriate place for that resident to receive those skilled services?


Myth #7: You never have to issue more than one notice regarding a Medicare stay at the same time.

If only that were a true statement. There are so many notices that it can be confusing trying to understand which notice is issued under what circumstances. To further complicate things, there are times when more than one notice will be issued at relatively the same time. Chapter 30, Section 261 of the Medicare Claims Processing Manual:

Delivery of the NOMNC does not replace the required delivery of other mandatory notices, including ABNs. Notice delivery must be determined by the individual NOMNC requirements per this section and ABN delivery requirements per §1879 of the Act and per guidance in this chapter. Both the NOMNC and an ABN may be required in certain instances.


This same manual section notes the following example of when both notices would be issued:

A beneficiary’s Part A stay is ending because skilled level care is no longer medically necessary and the beneficiary wishes to remain in the SNF receiving custodial care. The beneficiary must receive the NOMNC two days prior to the end of coverage. A SNFABN must also be delivered before custodial care begins.


Myth #8: There is never an instance where no notice is required at the end of Medicare coverage.

This is untrue! When a beneficiary exhausts his or her 100-day benefit period in the SNF, there is no notice required. The Beneficiary Notification Initiative (BNI) process allows beneficiaries to be notified and have the ability to appeal decisions being made by providers in relation to their Medicare coverage; the end of the 100-day SNF benefit period is not a provider decision, but rather a statutory end of coverage based on the Medicare guidelines, and there is nothing that the beneficiary can challenge or appeal. That said, it is recommended to communicate the end of the 100-day benefit period to the beneficiary, but no formal notice or form is required. – Billing Alert for Long-Term Care

Medicare Set Aside Exhausted – Private Insurance Required Auth

Has anyone else had a patient with a third party administering the patient’s Work Comp Medicare set-aside account, and the funds became exhausted, and your office was not notified? This company actually issued an EOB, but never funded the amount allowed on the EOB.

The additional issue here is the patient’s private insurance requires an authorization for services. Naturally, we did not have an auth for the private insurance because we did not know the set-aside account had been exhausted.

Wondering what the protocol is for the balance? Could the patient be billed? Is it patient responsibility to let us know if funds are exhausted?

Insight is appreciated!

Medical Billing and Coding Forum – Payer/Health Plan

New Hampshire BCBS Begins Participating with Medicare Part C & D

Medicare is a social health insurance backed and funded by the US federal government for senior citizens and for younger people with disabilities. Originally, beneficiaries of Medicare are provided with funding by the government itself, but with the inclusion of Medicare’s Part C, people can now opt to be covered through a network plan.

While third-party health insurance agencies like the New Hampshire Blue Cross and Blue Shield Anthem exist for beneficiaries opting for Medicare’s Part C and D, why would anyone want to choose paying more for something the government offers at a lesser price?

Medical Billing and Coding Process:

Anyone who has ever been hospitalized and has filed a claim for Medicare or Medicaid services should know how troublesome it can be. As wonderful and beneficial these social health insurance coverage can be, the process of them actually being wonderful and beneficial could take from a few days to a few months, depending on the nature of the claim. Imagine having to go through illness and disease, and processing an insurance claim at the same time.

Granted, health insurance like Medicare cannot help it when certain claims take too long to be processed. The reason for this is because as a government-funded and backed program, it caters to a whole multitude of people who essentially file claims at the same time. Imagine the staggering amount of paper and electronic forms that get submitted to Medicare carrier offices daily, and the reason for the delay seems clear.

Faster Processing with the New Hampshire Blue Cross and Blue Shield:

Fortunately, third-party insurance companies like Anthem can process these claims faster than if a beneficiary were to file a claim to the government or original Medicare program. This is because third-party agencies will get a substantially smaller bulk of claims as not all qualified beneficiaries opt to choose a third-party health insurance.

Furthermore, agencies like the New Hampshire Blue Cross and Blue Shield have affiliated pharmacies and physicians who all provide Medicare and Medicaid coverage. Should their beneficiary member seek treatment or prescribed medications from their affiliates, the process of medical billing and coding gets easier, as the interaction between the medical provider and the insurance agency is faster than it would be if the medical provider were to interact with a government-issued carrier.

For medical providers, opting to be affiliated with a third-party insurance agency can also prove to be more beneficial, especially when it comes to the process of coding medical bills. Medical bills can be so confusing that there are separate Medical biller to do the job. For a physician filing a medical bill under the government-centered Medicare, he or she will most probably complete the taxing medical coding and billing process. If he or she is affiliated with a third-party agency, he or she might not have to, as the agency will probably have a Medical biller on staff.

Though it might be true that going for a third-party option for Medicare and Medicaid will be more expensive, it can provide faster, smoother, and better handling with the troublesome coding, filing, and processing of medical bills.

Click Here to visit the New Hampshire BCBS website for more information.

Medical Billing Services » Medical Billing Blog

Medicare overbilled by $41.9M – Mount Sinai Hospital

New York City: According to a recent OIG report, Mount Sinai Hospital failed to comply with Medicare’s billing requirements for 110 outpatient and inpatient claims reviewed by the office of Inspector General for the audit period of January 1st, 2012, through December 31st, 2013.

Read the Full Story Here!

The post Medicare overbilled by $ 41.9M – Mount Sinai Hospital appeared first on The Coding Network.

The Coding Network

Medicare Advantage Organization and Former COO to Pay $32.5 Million to Settle False Claims Act Allegations

Freedom Health Inc., a Tampa, Florida-based provider of managed care services, and its related corporate entities (collectively “Freedom Health”), agreed to pay $ 31,695,593 to resolve allegations that they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans, the Justice Department announced today. In addition, the former Chief Operating Officer (COO) of Freedom Health Siddhartha Pagidipati, has agreed to pay $ 750,000 to resolve his alleged role in one of these schemes. You can read the full update on the website – here.

The post Medicare Advantage Organization and Former COO to Pay $ 32.5 Million to Settle False Claims Act Allegations appeared first on The Coding Network.

The Coding Network

Accepting payments from Medicare patients

We are a billing company and collect payments on behalf of our clients for the patient responsibility portion of the Medicare claim. The payment is processed through our bank as an aggregate. The question was asked if this is proper to accept these payments in our account on behalf of the client for Medicare patients? I cannot find anything that says that this cannot be done but I am looking for any feedback.

The money is allocated back to the clients at invoicing, every 30 days.

Medical Billing and Coding Forum – General Discussion

Medicare Payments Higher at HOPDs than ASCs, Doc Offices

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Medicare Payments Higher at HOPDs than ASCs, Doc Offices

Rene Letourneau, Senior Editor for HealthLeaders Media

Cardiac imaging payments are more than triple when a patient receives care at a hospital outpatient department instead of a physician office, roughly $ 2,100 versus $ 655, respectively, research shows, but quality was not studied. >>>


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Medicare Sparks Site-Neutral Payment Showdown

There is likely no clear winner in the fight between hospital and physician groups who are weighing in on Medicare’s new site-neutral payment policy that goes into effect next year. >>>

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Sepsis, Septic Shock Redefined in Consensus Statement

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Humana stock rises on proposed hikes in Medicare reimbursements

Louisville Business First, February 24, 2016

HHS failed to heed many warnings that was in trouble

The Washington Post, February 24, 2016

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U.S. News & World Report, February 24, 2016

FDA reform, privacy law standards needed in next healthcare overhaul, group says

Healthcare IT News, February 23, 2016

UPMC says insurer should cover its tentative $ 12.5M settlement in antitrust case

Pittsburgh Business Times, February 23, 2016

CA Legislature to advance health-plan tax

The News & Observer / Associated Press, February 23, 2016

Health startup Oscar shifts course in million-customer plan

Bloomberg, February 22, 2016

Blue Cross complaints top 1,400 as software problems continue

News & Observer, February 22, 2016

Why a CA hospital paid a $ 17,000 ransom in bitcoin

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IBM buys Truven, adding to growing trove of patient data at Watson Health

The New York Times, February 19, 2016

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[Announcement] Private Payor Prices Will Be Used By Medicare to Set Payment Rates for Clinical Diagnostic Laboratory Tests Beginning in 2018

Clinical Lab Tests

On June 17, CMS released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018.

The final rule includes provisions to ease administrative burdens for physician office laboratories and smaller independent laboratories. The final rule will generally require reporting entities to report private payor rates and test volumes for laboratory tests if an applicable laboratory receives at least $ 12,500 in Medicare revenues from laboratory services paid under the CLFS and more than 50 percent of its Medicare revenues from laboratory and/or physician services.

For the system’s first year, laboratories will collect private payor data from January 1, 2016, through June 30, 2016, and report it to CMS between January 1, 2017, and March 31, 2017. CMS will calculate and post the new Medicare rates by early November 2017. These rates will take effect on January 1, 2018.

For More Information:


See the full text of this excerpted CMS press release (issued June 17).

The Medical Management Institute – MMI – Medical Coding News & MMI Updates

Medicare Quality Reporting Rules are Changing

This year is the final reporting period under the now-familiar Physicians Quality Reporting System (PQRS). The Centers for Medicare and Medicaid Services (CMS) just announced proposed regulations that will govern new Medicare quality-reporting rules known as the Quality Payment Program (QPP) beginning in 2017.  This new system, which was enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), comprises both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).  The final rules will be published later this year, but physicians can begin now to explore whether they want to join an APM or adapt to the MIPS reporting requirements. 

Medical Billing and Coding Blog