Hello All,
Here’s the list of responses to my question regarding consolidated billing. By
the way, after an incredible amount of confusion, investigation, and questions,
our patient did turn out to be under part A, (she had 6+ different hospital
stays and as many or more different SNF locations this past year). Fortunately
due to a good relationship with the current SNF we are receiving payment.
RESPONSES:
By far the number one response was to contact Kathy Dobson at AOPA.
A close second is Joe McTernan, who wrote in the Dec-Jan OP Almanac on the
reimbursement page regarding this subject. His suggestion made the most sense
however, and that was to contact the SNF before delivery and have them verify
whether or not the pt is on A or B and (response number 3) get a PO, and or get it in writing about the pt status.
The worst response was the CMS website (revised in the past 3 weeks, and just
about worthless in my opinion, but that may just be me).
Attached are a couple of files regarding the SNF consolidated billing.
Response #4 First off, good luck! Secondly, I am sorry that I can’t answer your
question but here is a thought on your situation. Things may not be as
bleak as they seem. Take the auditor’s naivete as an advantage to your
position. Because they have obviously not been educated from their side
they are a weak adversary.You have the opportunity to educate this
individual from your point of view and be the authority. He/she is
essentially a blank slate.
Once again, good luck! Let us know how it goes.
Response #5 First don’t panic. Email or call Kathy Dotson at AOPA. She knows all.
Also, when you fitted the patient at the SNF, did you obtain a face sheet
from the facility. If so, it should state the admit date. If your dos
is past the 100 days of admit, show it to the reviewer. If not, you’ll
need info from the other facilities she/he has been at. I don’t believe
that the 100 days starts over if she goes into a hospital for a short
stay during the snf stay, but check with Kathy D on those questions.
Response #6 The attached file might help you. I have found that patients who have
been in a snf more than 100 days can have their benefit periods altered
by several things, including: a change of diagnosis, a lengthy hospital
stay, returning home, or a requalifying hospital stay. Remember, it is
generally to the snf’s advantage for the patient to qualify for a Part A
stay. The question I always ask is, “Is the patient in his or her Part A
stay?” If the answer is yes, we can’t get paid under Part B. I used to
ask if the patient was over 100 days, but then I found that even if they
are, they may have had their benefit period renewed at some point
(meaning Part A coverage for the snf- no Part B for us). Good
Response #7 Medlearn Matters Number SE0507 explains who is responsibile for billing
when a customized device is ordered for a beneficiary while in the
hospital OR home but delivered to the beneficiary at a SNF.
Response #8 I am not sure this will be information you WANT to hear but I will try to
explain this issue as clearly as I can. If this in information you already
know, please forgive me. Also, there may be some differences in policy
between the different DMERC regions. I am from Region B. I would think
that most of what I say applies to your Region, but I would not assume
anything. Use this information as a base from which you can ask other
questions.
A Medicare patient that goes to a skilled nursing facility (SNF) initially
is on a part A stay. This means that the SNF is paid by Medicare for most
everything that the patient needs through a per diem payment. Orthotics are
included in this per diem payment. Prosthetics, because they are usually
more expensive items, are NOT included in this per diem payment. Therefore,
if you supply orthotics to a Medicare SNF patient that is in a part A stay,
you cannot bill the DMERC for your services because, supposedly, the DMERC
is already paying the SNF for them. You must bill the SNF for those
services and have to make arrangements with the SNF to pay the bill
(preferably before the date of service). Some of our professional
organizations are lobbying Congress to get orthotics excluded from the per
diem so that they can be billed directly to the DMERC like prosthetics. I
was in Washington last summer with AOPA to push this issue forward but it
has not succeeded yet. Once the patient has stayed in the SNF for 100 days,
their stay is no longer a part A stay. Their stay is now paid as a part B
stay. For O & P providers, this means that orthotics can now be billed
directly to the DMERC and we like that.
Seems pretty clear, right? Well, it is unless the patient has another
hospital stay. If a patient is in a part B stay in a SNF and has to go to
the hospital for an in patient stay and then goes back to the SNF (same one
or different SNF), guess what…they start a part A stay all over again and
we go back to billing the SNF for orthotics until they are there 100 days
and get in to another part B stay. This can happen an unlimited amount of
times to one patient. There are some conditions that will confuse things
even more but may work in your favor. If the patient goes from hospital to
SNF back to hospital and back to SNF within 100 days, I don’t think they
start the 100 days over again if the second hospital stay was for the same
ailment that the original hospital stay was for–but I would definitely
check that out.
One other thing: orthotics can be provided to a SNF/hospital patient and
billed to the DMERC in a part A stay if the device is provided within 2 days
of discharge, the device is not used at the hospital/SNF for any purpose but
being trained to use it and it intended solely for home use. If the patient
is going from the hospital to the SNF, you could not bill the DMERC for
orthotics.
O & P providers depend on SNFs for information concerning what stay a
patient is in. I am not suggesting that SNFs would purposely give you
misleading information but it pays to know what questions to ask a SNF:
when was the patient admitted for their current stay, did they come from a
hospital and when, where do I get a purchase order if the patient is in a
part A stay, etc. Be wary of patient data sheets from a SNF that has an
admit date-the date may not be correct. There is a lot of work to get in a
SNF but you have to manage the relationship. SNFs are in the same boat as a
lot of healthcare providers with caps on reimbursement and higher expenses
that can’t be passed on. We have been asked to wait until a patient is on
Part B to provide services several times and who benefits from that?
Certainly not the patient. There has been enough problems with the
relationships between SNFs and O & P providers that CMS has stated that
ultimately SNFs are responsible for paying us, regardless of what
information was or was not given, when a patient is in a part A stay. CMS
first wanted all O & P providers to sign individual contracts with SNFs to
lay out payment responsibilities but this was retracted by CMS. When
something like your case happens, it can be problematic trying to go back
and bill the nursing home, especially if it is a new relationship that you
want to keep. CMS will probably change the playing surface again at some
point in the future, hopefully to exclude orthotics from SNF part A
payments.
Where can you go to get the information and guidance? The list serve for
one. Your colleagues. Your own experience is also a good, if sometimes
painful teacher. If you are not already doing so, check your DMERC
bulletins. I find these to be a good source of information and are
available on the web. They also have a good index. I have also found AOPA
to be very helpful in educating our staff and answering questions when they
occur. You have to pay to join but I think it has been worth it. We have
sent some of our staff (administrative staff and practitioners) to their
coding and billing seminars and I think this has been very helpful too. It
is not cheap but the alternative of feeling your way blindly is usually more
costly than the $1200-$1500 or so that you will pay to send someone to a
seminar. You can also email them questions and they are pretty good about
responding.
I hope this helps. If you have any other questions, I would be glad to help
if I can. Good luck in your case. Don’t feel too bad, though, because you
are not alone. We just had to repay CMS in a very similar case and I think
we asked the right questions.
You should not have to educate your investigator, though. If anything, they
should be educating you…
Thanks to all who responded! Hope this helps.
Michael S. Johnson CPO
OrthoPro of Twin Falls, Inc.
762 North College Road
Suite A
Twin Falls, ID 83301
ph: 208-733-0505
fax: 208-734-0766
