Medical billing is a critical aspect of the healthcare industry. SNFs, in particular, require specialized experts who understand the process in-depth. For the specialist, a thorough comprehension of the distinctive aspects of the industry, regulations, requirements, and medical billing skills (proficiency in medical coding and terminology, familiarity with SNF consolidated billing, competence in industry-specific software, experience with claim forms, etc.) is essential. Moreover, understanding the peculiarities of insurance programs, such as Medicare and Medicaid, along with their billing requirements, is vital to ensure accurate reimbursement.
This article aims to provide a comprehensive guide for becoming an SNF medical billing expert, covering the essential medical billing skills and knowledge required, the differences between Medicare and Medicaid, industry-specific features, and how to stay abreast of industry trends.
Understanding the Medical Billing Process in an SNF
Skilled nursing billing is a complex process, which involves several key parties, including the biller, the patient, and the insurance company. The primary objective is to ensure the submission of claims that are both timely and accurate, resolving any rejections or issues that may arise while maintaining transparent communication among all parties.
The first step is to gather the patient’s personal data, medical history, and functional status. The recording of the medical ailment and the recommendations provided by healthcare professionals regarding the patient’s condition will hold significant importance in determining the patient’s acceptance into the Skilled Nursing Facility (SNF), shaping the course of treatment, estimating the expected duration of their stay, and establishing the payment arrangement for the facility services. The biller must check whether the data is correct and verify the patient’s policy to ensure they have appropriate insurance benefits.
Next, the biller needs to obtain prior authorization from the insurance company before providing services to the patient. This process may involve submitting additional documentation or answering questions from the insurance representative regarding the medical necessity and appropriateness of the services being provided. The absence of proper authorization may lead to further claim and payment denials.
Once prior authorization has been obtained,, correct billing codes for the services provided must be assigned (procedure codes, diagnosis codes, and revenue codes). There are significantly different code sets and coding criteria for SNF billing than for healthcare provider billing.
During the provision of services to a patient, it is the responsibility of the biller to work closely with the healthcare team, ensuring that the services provided align with the patient’s care plan. Once the services are accurately documented and coded according to nursing home billing guidelines, the biller will prepare a claim and submit it to the patient’s insurance company. The accuracy of the coded claim is vital to ensure proper reimbursement.
Proper coding is an essential component of the SNF billing process and plays a critical role in ensuring appropriate reimbursement. It prevents claim errors, denials, and delays in payment, all of which can significantly impact the financial health of the SNF. As such, billers should prioritize their focus on coding to ensure it is done correctly.
Essential Skills for Medical Billers in an SNF
The billing role requires a range of essential skills and qualities to be successful. Let’s examine the primary ones required for an individual to perform effectively in this sphere.
Familiarity with medical terminology and coding
A biller in an SNF must have a deep understanding of medical terminology and how to use standardized coding systems, such as ICD-10 and CPT, to describe the services accurately.
There are a few skilled nursing facility billing codes that must be considered:
- ICD-10 (International Classification of Diseases) codes, used to describe the patient’s condition and the reason for the SNF stay.
- CPT (Current Procedural Terminology) codes, used to specify the services provided to the patient (procedures, treatments).
- HCPCS (Healthcare Common Procedure Coding System) codes describe medical supplies and services that are not covered by CPT codes. Nursing homes may use them to bill for durable medical equipment provided to patients.
- Revenue Codes, like HIPPS (Health Insurance Prospective Payment System), used to identify the specific services provided, such as room and board, cost of meals, rehabilitation therapy, or medical supplies.
While coding, it is important to consider the levels of care that indicate the group of medical procedures provided to the patient:
- Level 1 – for skilled nursing or SNF
- Level 2 – for subacute care or SAR
- Level 3 – Specialty Skilled Care
- Level 4 – Custodial level
In addition, SNF consolidated billing requires that all services provided to a Medicare patient are billed in a bundle under the Patient-Driven Payment Model (based on resident characteristics rather than therapy minutes) that uses a single code. This model classifies patients into one of 10 clinical categories based on five components: physical therapy, occupational therapy, speech therapy, nursing, and non-therapy ancillaries. Billers need to be aware of these components and know how to calculate the code properly.
Medical billing codes constantly evolve, so it’s vital to stay up to date with the latest coding guidelines and regulations (especially the Medicare billing guide). This practice ensures accurate billing for services rendered, thereby helping SNFs generate revenue and provide patients with the essential care they need.
Analytical and Detail-Focused Abilities
Good analytical skills and attention to detail are critical in the field of skilled nursing facility billing. A person must have the ability to review patient medical records and identify the specific services that are billable to payers. They must also be able to identify any discrepancies or errors in billing documentation and take corrective action as needed. Failure to spot even tiny details can result in denied claims or delayed payments, so attention to detail is critical.
To compare medical procedures and diagnoses, understand insurance policy limitations, and determine the best approach to bill for services according to SNF billing guidelines, the person must have strong analytical abilities. In addition, data analytics allows billers to optimize the reimbursement process by identifying any areas for improvement and taking corrective action.
Understanding of insurance regulations and requirements
Medical billers in SNFs must have a solid understanding of insurance regulations and requirements. It is critical to have the ability to navigate complex insurance systems like Medicare and Medicaid and understand the specific rules and regulations for each payer source, including billing timelines, documentation requirements, and reimbursement rates.
A valuable resource is the Medicare billing guide, which outlines the rules and regulations for billing Medicare for various healthcare services, including those provided in an SNF. As for Medicaid, a biller can refer to the Provider Manual available on the Medicaid state website (check your particular state) – it provides essential guidance on claims submission, reimbursement, coverage policies, and procedures.
Moreover, internal nursing home billing guidelines must be followed to ensure compliance. These guidelines include information on how to submit claims, what facility services are covered, and what documentation is required to ensure accurate and timely reimbursement.
Strong communicational skills
Strong communication and interpersonal skills are vital as billing requires a lot of interaction with physicians and nurses to ensure that all billable services are properly documented and coded. Billers must also be able to communicate effectively with patients and their families, providing them with information about their insurance coverage in a clear and compassionate manner.
In addition, good communication skills help navigate complex billing issues and disputes. Payers may deny claims or require additional documentation, and billers must be able to communicate efficiently to address these issues and resolve any disputes.
Problem-solving skills to address billing issues and discrepancies
Problem-solving is essential in complex medical billing, and a specialist must be able to identify and address issues and discrepancies promptly. This requires the ability to analyze complex billing documentation, identify potential errors, and develop appropriate solutions. To apply such skills effectively, medical billers must first identify the problem and gather all relevant information. Facility billing guidelines may recommend developing a plan to address the issue, which involves working with physicians, nurses, and insurance representatives to gather additional information or documentation.
Medical Billing Certifications
To demonstrate their expertise and knowledge, billers can pursue various certifications. One of the most respected and widely recognized is the Certified Professional Biller (CPB) credential offered by the American Academy of Professional Coders (AAPC). This certification validates essential billing skills, including knowledge of regulations, compliance, and medical terminology. Another certification available to billers is the Certified Medical Reimbursement Specialist (CMRS) credential offered by the American Medical Billing Association (AMBA). It focuses on the legal and ethical aspects of medical billing, as well as coding and compliance.
Obtaining these credentials can provide numerous benefits, including credibility, a competitive advantage over other billers, and new opportunities for career advancement. Staying up to date with industry trends and changes is crucial for work efficiency, and consistently learning and obtaining new credentials can help achieve this goal.
Working with Medicare and Medicaid
Government-funded Medicare offers insurance to individuals who are over 65 years old or people who have certain disabilities. The coverage consists of four parts for different types of medical care. Nursing homes should pay attention to Medicare Part A and Part C as they cover skilled nursing care (up to 100 days per benefit period, subject to certain limitations).
Medicaid, funded by both the government and the state, offers insurance to individuals with low income. Eligibility criteria may vary by state and may consider additional factors, such as pregnancy or disability.
To ensure proper payment for services, a biller must carefully review cost-sharing obligations. Medicare or Medicaid beneficiaries may be responsible for out-of-pocket expenses. Thus, it becomes critical to carefully check and verify their insurance policies before providing care.
Additionally, billers must follow the regulations and requirements of the SNF Prospective Payment System, under which payment rates are predetermined based on various factors and classifications, which ensure compliance and allow for more predictable reimbursement. Key regulations to watch out for in Medicare skilled nursing facility billing under this system include:
- Patient-Driven Payment Model (PDPM)
- Minimum Data Set (MDS), used to collect patient data and determine care needs.
- 3-day Rule: Medicare requires that patients should be admitted to a hospital for at least three consecutive days before being eligible for skilled nursing care.
- Conditions of Participation (CoPs): according to the Medicare SNF billing manual, facilities must meet certain conditions to be eligible for reimbursement, including requirements related to patient rights, care planning, and infection control.
- Time limit: Medicare has a limit for submitting claims, typically one year from the date of service.
Medicaid also has a few specific requirements for billing.
- Retroactive eligibility: Patients may be eligible for Medicaid coverage retroactively 90 days from the date of application. Billers must be aware of their state’s policies on this matter.
- Managed care: In some states, Medicaid beneficiaries are mandated to join managed care plans, which may have their unique billing prerequisites.
More regulatory information for both programs can be found on the CMS website. In particular, we recommend checking the Medicare billing guide. Other professional associations that provide essential medical skilled nursing billing knowledge are the American Health Care Association (AHCA), National Association for Healthcare Revenue Integrity (NAHRI), the American Association of Professional Coders (AAPC), American Health Information Management Association (AHIMA).
To maximize reimbursement while working with Medicare and Medicaid, it is vital to ensure accurate and complete documentation and stay up to date on regulatory changes. Another strategy to implement is the use of technology tools for streamlining billing processes and reducing errors. These include using electronic health records (EHRs), automated eligibility verifications, claims submission, and denial management systems.
The Importance of Changes Tracking for Medical Billing Success
As medical billing is subject to constant updates in patients’ policies, payer requirements, and regulations, it is essential to effectively track these changes to ensure compliance and maximize reimbursement.
One of the most critical elements that need to be tracked is the patient’s eligibility, due to the frequent changes in insurance plans, coverage periods, or personal information such as income or address. If a biller fails to conduct proper verification, he/she may submit a claim for services that are not covered, resulting in denial and lost revenue.
This is where an automated verification tool, like Approved Admissions, can be a game-changer. It tracks policy changes automatically and sends notifications regarding coverage periods, benefit limits, and other policy-specific information. Such software can significantly reduce the need for manual work, minimizing errors and inaccuracies, thereby leading to more accurate billing.
Another critical area for skilled nursing is the constantly evolving regulations for Medicare and Medicaid billing, such as the Patient-Driven Payment Model (PDPM). To ensure accuracy, billers must stay up to date with the latest regulatory changes. This includes keeping track of changes to payment models, coverage criteria, and billing codes.
To implement change tracking in medical billing, clear communication channels with the rest of the skilled nursing facility team should be established. Billers should also regularly monitor industry updates, policy changes, and regulatory updates. This can be achieved through various means, such as subscribing to industry publications, attending conferences, or joining medical billing associations.
