When searching for a HIPAA-compliant billing company, providers tend to consider criteria such as certification, turnaround time, and cost. One criterion that is not often considered, however, is whether this billing company has previously worked with long-term care claims. Regarding skilled nursing, assisted living, and home health facilities, this criterion speaks louder than any other.
Long-term care operates with its own rules, its own timeline, and its own payers. A biller who is accustomed to filing claims for clinics will make costly errors and not even know it.
Claim Coverage
In the outpatient office, the claim is the encounter. People come in, people do stuff, people write the claim for it. In long-term care, the claim is the stay, and the stay changes while billing occurs.
There is a change in the level of care provided to the resident. There are increases and decreases in minutes of therapy. The payor changes midway through the month. There is a three-day hospital stay, and it starts the clock over again. All of these factors affect what can be billed, and all of these factors need to be identified prior to the claim going out.
The difference is seen by billers who have experience only billing encounter claims, because it will show up as unbilled revenue.
Medicare Part A Peculiarities
Benefit period, qualifying stay, 100-day cap, change to coinsurance on Day 21. You learn all these things, and they become second nature once you know them, but they are hard to figure out at first.
Mistakes happen at all facilities. Days are billed for an ineligible resident because the beginning of the benefit period is not known. The qualifying stay is automatically assumed instead of being verified. Days are never billed for coinsurance to the secondary because no one noticed the change. The interrupted stay is billed as continuous and rejected, but the problem remains unresolved.
Someone doing the claims every day will figure out how to do these checks on their own.
Medicaid Has Different Rules for Each State
Medicaid guidelines, forms, deadlines, and calculation of patient liability depend on the state, and for long-term care, Medicaid could account for a big share of the census.
Medicaid guidelines, forms, deadlines, and calculation of patient liability depend on the state, and for long-term care, Medicaid could account for a big share of the census.
Patient liability always causes headaches. It is computed depending on the state, fluctuates depending on income and circumstances, and has to be computed right before submitting. If not, then the claim will be either underpaid or denied, and will require correction after many weeks.
Another factor that needs to be considered is pending cases. Here, the resident is admitted when his eligibility is being processed. The person in charge monitors the application, properly holds the claims, and bills retroactively as soon as the approval is processed, and everything is done within the filing deadline. Facilities without the discipline will miss months of revenue because of the deadline.
The Importance of Secondary Coverage
Primary insurance is always verified, because nothing happens without it. Secondary insurance remains in the chart from when the person got it, which could have been many years back, and is hardly ever checked again.
This is very costly in long-term care. Once Medicare pays its share, the remaining part is covered by the secondary insurance. The insurance marked in the chart has been long discontinued for many months now. The claim is denied; the bill is placed on the resident/family’s account and left unpaid. Eventually, the bill becomes a write-off, although an active payer exists throughout this entire process.
Long-term care billers with experience verify secondary insurance before billing each patient. It takes only a few minutes and stops the write-off that cannot be recovered through appeals.
Documentation
The nurses, therapists, aides, and MDS coordinator compile this facility’s record. Most of them chart for medical and legal reasons and rarely consider reimbursement.
Since the MDS assessment leads to reimbursement, a delayed or incorrect MDS assessment means the loss of money. The therapy logs need to correspond to the billed services. Physicians’ orders should be updated.
A biller who knows all of these facts operates at an earlier stage. He tells the MDS coordinator about the imminent deadline and its price tag. The therapy director is informed about the importance of signing the logbook now. Such knowledge makes all the difference while there is still time to make it.
What to Ask a Potential Partner
Try to understand how the partner actually handles day-to-day billing work. Look at the number of nursing homes they support and how responsibilities are divided, especially for Medicaid pending applications, secondary insurance checks, and missing or delayed MDS information.
Their answers should give you a good sense of how organized their process is and how they deal with common billing issues.
Key Takeaways
Long-term care billing requires particular expertise. Your case is evolving as you are billing it. The laws on Medicare Part A are very stringent and can be violated easily. Every state is different regarding Medicaid, and there are liabilities to calculate, as well as pending applications that clinic billers have not dealt with before. The secondary insurance coverages need to be validated for each bill.
An expert with experience in long-term care can use his knowledge to identify potential issues when there is still money left to collect.
