SNF Billing Services For Skilled Nursing Facilities
UControl Billing is responsible for coding and reimbursement of skilled nursing care claims based on the Patient-Driven Payment Model under Medicare. The process entails transforming MDS assessment information into a daily case-mix grouping to determine the daily payment amount.
A resident’s admission gives rise to claims for one benefit period under Part A and excluded services. The whole process is executed by our team with expertise in PDPM and consolidated billing and denial recovery.
- PDPM five-component classification
- Consolidated billing exclusion accuracy
- Part A benefit-period tracking
- Denial and AR recovery included
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Common PDPM Billing Errors and How UControl Billing Team Fix
The problem of misclassification typically results from inadequate and/or delayed MDS documentation.
Qualifying comorbidities for NTA scoring go undocumented and decrease the rate.
Missing chances for IPA result in keeping the old classification despite a change in the resident's health status.
Therapy minutes assigned incorrectly to the wrong therapy discipline inflate the PT and OT scores.
An inconsistent functional score generates an inconsistent grouping that cannot be supported by the record.
UControl Billing highlights each of those problems before the claim becomes an underpayment or an audit risk. Our experts verify the accuracy of the MDS documentation about the classification. The component scores and stay days now correlate with the record.
What UControl Billing Runs Across The SNF Claim Lifecycle
The accuracy of MDS determines the PDPM classification that influences the consolidated billing claim during the Part A benefit period. Front-end accuracy relies on the fact that you need to be actively enrolled and have clean EHR-to-claim data. This coordination for each payer comes from the coordination of Medicare, Medicaid, and Medicare Advantage
PDPM classification review
MDS data entry will be reconciled with the billed case mix groups prior to submission. Component points and stay days will be verified such that the per diem rate is correct.
Consolidated billing exclusion tests
Charges from external providers are divided into those that are bundled or billable. This is to avoid double payment for services that were excluded and un-billed bundling.
Claims processing and scrubbing
PPO SNF claims are scrubbed to ensure benefit period accuracy and format per payer before being processed by Medicare. Edits identify coinsurance switches and benefit period lags during claim submission. See claims processing and scrubbing.
Specific reasons for denials for PPO SNFs are managed. It includes medical necessity denials and prior authorization denials for MA patients. See denial management.
Patient bills and statements
The resident coinsurance for days 21 to 100 is billed using detailed patient statements. The accuracy of the statements is based on the same benefit period tracking process as the Medicare claim itself.
Claims at the facility level are monitored according to aging buckets, meaning that the older claims are collected prior to filing deadlines. See account receivable collection.
Proper diagnosis and component codes match up with the MDS and the PDPM payment formula. Proper coding upfront eliminates recording later. See medical coding.
What Makes UControl SNF Billing Different From Others
We create SNF claims from the case-mix approach. The per diem rate would reflect the clinical picture, not any group by default. The per-diem nature is what makes SNF billing distinct from the other methods used in post-acute care.
The difference is critical in how UControl Billing rates each admission. Only when there is a physician’s order of skilled nursing or therapy from a licensed professional can Medicare Part A pay for a resident’s admission. Simple custodial care is not enough.
The new PDPM has superseded the old system which is called Resource Utilization Groups, also known as RUG-IV. The payment approach changed from the volume of therapy to clinical features of the residents. Our team creates claims based on those clinical features, not on minutes of therapy only. This is how outsourcing begins in most facilities. The internal staff needs to measure the accuracy of PDPM together with denial and staff turnover. This is one of the key features of our SNF Billing Services.
Per-diem · PDPM Skilled nursing
The payment per day depends on the classification from MDS. The payment considers five clinical components which vary throughout the stay through Medicare Part A.
Episodic · PDGM Home health
The payment categorizes a 30-day episode of care and not the payment for each day. The payment scheme is different from SNF case-mix and belongs to another benefit.
Per-diem levels Hospice
The payment depends on the level of care provided each day based on the intensity of care. The payment is not based on case-mix diagnosis.
UControl Patient-Driven Payment Model and What It Means For Reimbursement
Our experts assign costs per covered SNF day according to the six rate components of PDPM instead of one therapy-based rate. The new rule began on October 1 2019 through the Prospective Payment System for SNFs which succeeded the old system of RUG-IV. Of the six, five rate components vary per resident whereas one remains constant.
| Component | Basis | What drives the rate |
|---|---|---|
| Physical Therapy | Case-mix adjusted | Primary diagnosis, clinical category along with documented functional status using MDS. |
| Occupational Therapy | Case-mix adjusted | Functional level and clinical category, each having its own separate pricing from PT. |
| Speech-Language Pathology | Case-mix adjusted | Acute neurological issues, problems with swallowing and cognitive impairments. |
| Nursing | Case-mix adjusted | Level of acuity and functional needs linked to a nursing case-mix group. |
| Non-Therapy Ancillary | Case-mix adjusted | Comorbidity and broad range of services, measured by weight points. |
| Non-case-mix | Case-mix adjusted | Flat fee for room and board plus routine services for all residents. |
We use the variable per diem schedule used by three components during a stay. The PT and OT rates reduce according to a schedule following the initial days of care. The NTA component charges a high rate during the initial three days before reducing to its standard rate.In this way, the payment is weighted towards the period where utilization is greatest. It is vital to use the right day count in billing because it impacts the adjustment of each component. An inaccurate count of the stay day would affect the rate adjustment to the wrong step, a problem detected by our team in similar cases before submission.
UControl SNF Consolidated Billing: What Is Bundled and What Is Excluded
Our billers categorize bills submitted by outside providers based on their bundled or non-bundled nature. There will be no overbilling or unbilled expense anywhere. We ensure that the SNF bills Medicare for almost the whole range of provided services. There are numerous outside providers whose services are subject to this regulation. The facility gets the consolidated billing payment and then reimburses these outside providers. Our team exploits this regulation in order to avoid duplicate billing for one episode of skilled nursing care. The therapy and most drugs and ancillaries provided to the resident are included into the bundle. There is a clearly specified list of the categories excluded from the bundle and charged separately from Medicare.
Excluded and separately billable Verify vs CMS
- Professional services of physician and certain non-physician practitioners
- Certain dialysis-related services, including ambulance transportation for dialysis
- Certain ambulance transportation to SNF at admission and from the SNF at discharge
- Certain chemotherapy drugs and chemotherapy administration services
- Radioisotope services
- Customized prosthetic devices
- Certain blood clotting factors
Inside the bundle (SNF bills Medicare)
- Physical, Occupational and Speech/Language Pathology Services
- Most routine drugs and biologicals provided during the stay
- Nursing services and routine clinical care
- Room and Board and Routine Ancillary Supplies
- Diagnostic services not included on the exclusions list
- Other outside services that are part of the covered bundle
Medicare Coverage Mechanics UControl Billing Manages
We track each resident’s position within the benefit period. Coinsurance transitions and resets then post to the claim on the correct day. The team oversees the Part A coverage requirements that determine how much a facility may charge for services provided and when such billing is permissible. Medicare Part A Coverage starts with a qualifying three-day consecutive inpatient hospital stay. Observation time does not qualify as part of those three days. Our team monitors every resident relative to the coverage requirements that start after the admission.
Days 1 – 20 Comprehensive Coverage
The Medicare Part A insurance program provides comprehensive coverage for the first twenty days for an approved stay in the SNF facility.
Days 21 - 100 Coinsurance per Day
The patient must pay coinsurance on a daily basis for days twenty-one to one hundred.
Days 101+ Patient Pays Full Cost
After the first hundred days, the patient will be responsible for paying for the full cost of care
UControl Billing Ties NOA Filing and MDS Accuracy To One Intake Review
We submit the Notice of Admission, which marks the beginning of the Part A benefit period in terms of billing. This form substituted the previous Notice of Election procedure for the SNF stays. The form is submitted by a facility during the specified time frame since its admission. Verify the specific day count from CMS.
Our team always submits it in time. Late or missed NOA submission decreases the payment for the days before acceptance. Submission is based on admission information obtained accurately at the time of admission. It comes from the very same clinical record that provides information for classification.
The Minimum Data Set is the clinical record behind both the NOA and PDPM classification. Each case-mix variable derives from the specific coded MDS item. An inadequate assessment results in an inadequate classification and NOA submission.
SNF Billing Across Payers, Medicare, Medicaid, and Managed Care
Medicare Part A and Medicaid/Medicare Advantage have different policies when it comes to the same level of skilled care. Our team documents all three under one medical record.
Medicare Parts A and B in the SNF environment
Part A will reimburse for the full package of skilled services under the PDPM daily rate. Part B is involved only if there is no Part A coverage left or for some excluded services. Both parts have their own forms of claim and different eligibility documentation for the same patient.
Skilled nursing facility Medicaid billing
Medicaid nursing facility payment uses a case-mix/rate methodology unique to each state program rather than the national PDPM methodology. Because each state uses its own methodology, a Florida facility and an out-of-state facility can use completely separate rate methodologies when submitting a Medicaid bill.
Medicare Advantage concerns
A number of Medicare Advantage programs require prior authorization for SNF admissionVerify compared to the current program requirements. Coverage limits and cost-sharing arrangements may be structured differently from Medicare. Failure to obtain prior authorization turns a covered benefit into a denied claim, regardless of the clinical necessity.
Outsourcing Versus In-House SNF Billing
We act as a third-party extension that provides continuity of SNF billing expertise amid staff turnover. Accuracy of SNF billing will depend on the employees who can understand the logic of PDPM and billing exclusions simultaneously. The employees in the organization possess such skills along with hiring and attrition risks.
| Function | In-house billing team | Outsourced to UControl Billing |
|---|---|---|
| PDPM expertise | Depends on individual staff knowledge and their tenure at the facility. | A team that classifies SNF stays daily across facilities and payers. |
| Coverage continuity | Turnover or absence leaves claims unworked and AR aging. | Claims worked continuously without single-person dependency. |
| Regulatory tracking | Staff monitor CMS updates on top of daily billing duties. | PDPM and consolidated billing rule changes tracked as core work. |
| Denial follow-up | Competes for time against front-end claim submission. | Denials and appeals worked as a dedicated function. |
| Cost structure | Fixed salaries plus software plus training regardless of volume. | Scales with census rather than fixed headcount. |
SNF Provider Enrollment And Credentialing
The Medicare Enrollment process is conducted through the CMS-855A institutional application form as opposed to the CMS-855I practitioner application. Invalidation of the enrollment leads to non- adjudication of the SNF PPS claims, irrespective of whether the services provided were clinically accurate. Credentialing errors manifest themselves in claim rejections at the front end and not clinical denials. A failure to revalidate by the deadline will cause deactivation of billing privileges. A delay in filing the CHOW will interrupt payments. Our billing team keeps track of CMS-855A deadlines for enrollment and revalidation for each payer roster. The billing privileges remain intact with respect to Medicare and other plans.
CMS-855A – Institutional enrollment
The facility must first enroll as an institutional Medicare provider before filing any Part A claim
Revalidation of enrollment
Periodic revalidations of the enrollment are required based on the cycle of the contractor for Medicare.
CHOW – Change of ownership
Filing for change of ownership activates a transfer or update of the Medicare enrollment.
Managed care enrollment
Separate enrollment rosters exist for Medicare Advantage and Medicaid managed care plans.
UControl SNF Revenue Cycle Management Service Models
The level to which an organization utilizes billing depends upon their requirements for the facility’s operation. Some maintain their own staff but get additional support from specialists. Others choose to outsource the entire cycle from MDS reviews to collections.
| Model | Model Discription | Applicable to |
|---|---|---|
| Model 01 Complete SNF billing | In Model 01, our team manages the entire process of SNF billing from the time of PDPM review until collections of accounts receivable. Clinical staff remain focused on patients rather than paperwork | Those who lack a dedicated billing team or those who would like to replace their current vendor. |
| Model 02 Specialist support | While maintaining an in-house team, we deal with the processes at which mistakes tend to accumulate. These include PDPM review and denials and aged AR. | Facilities with billing staff requiring expertise in hard claims regarding SNFs. |
| Model 03 Billing audit & recovery | The scope-based review will analyze classifications and billing splits on consolidated claims and aged claims. Results include a detailed report showing underpayment and misclassification of revenue. | Facilities that would test the accuracy prior to adopting the service model. |
EHR and Billing Software For Skilled Nursing Facilities
Our process serves as the integration point for the transition from MDS/EHR to the claim. Once entered in the clinical record, the information then flows down into the claim without requiring re-entry. SNF billing relies on a host of clinical and finance applications that need to seamlessly exchange data. MDS assessment exists in the clinical record that determines the PDPM grouping, which the billing system subsequently transforms to the Medicare claim.
Clinical / MDS MDS and assessment systems
Minimum Data Set is encoded in the clinical solution and drives each PDPM component. Timing of assessment and accuracy of the sections determine the limit of billable reimbursement.
SNF PM / EHR Facility EHR and PM solutions
Long-term care EHRs and practice management software systems maintain census and orders and charges. Accuracy of claims relies on the accuracy of this information flow into the billing system.
Claims/Clearinghouse Billing and clearinghouse solutions
The clearinghouse edits and processes the SNF PPS claim for Medicare and secondary insurance providers. Edit criteria ensure accuracy of format and eligibility before claim is submitted.
SNF Billing Compliance, Audits, and Data Security
Our team supports each of the PDPM categorizations and maintains records in compliance with HIPAA as well as 42 CFR Part 2 regulations. This will ensure that claims withstand post-payment review without being reversed.
The process creates SNF claims because of the continuous audits conducted by this payment system. Both the PDPM classification and therapy documentation are audited by CMS and payers after payment. A claim that has been made today will be taken back later if the case documentation cannot justify the case-mix group.
The billing process also takes into consideration SNF record handling, which goes beyond health data privacy regulations. Substance abuse disorder records maintained by a facility have their own confidentiality regulations apart from HIPAA. Billing processes take care of these records based on both regulations.
PDPM audit defense
Documentation of each case-mix group to its MDS source ensures a claim survives post-payment auditing. The classification is dependent upon the documentation rather than the best case scenario.
HIPAA / 42 CFR
Patient records flow within billing processes under HIPAA regulations. The substance abuse records add another regulation in 42 CFR Part 2 to the mix. Access is restricted accordingly.
Medical necessity
The skilled nursing care should be documented as medically necessary and ordered by physicians in order to justify the stay from level of care denial.
Why Skilled Nursing Facilities Choose Us
SNF billing is a specialty within revenue cycle management, not a keyword attached to a generic service. UControl Billing handles the mechanics of the process that determine which SNF claims will be paid in full.
PDPM classification complexity
Each SNF admission is classified by PT, OT, SLP, Nursing, and NTA components. Our team classifies the individual components to the MDS instead of applying a default grouping to the claim.
Precision of consolidated billing
Categories such as physician services and chemotherapy drugs that are not included in the bundled service are separated from the bundled service. It is at that juncture where outside provider charges are dropped and/or double billed.
Full lifecycle – Same team for the claim
One team manages classification and claims scrubbing, denials, and accounts receivable recovery. There is no transfer of the claim through multiple vendors during the process.
Audit-defensible
Every classification is traceable to the MDS source by HIPPA and 42 CFR part 2. The claims are constructed to withstand CMS review following payment.
Medical Billing Certifications and Compliance Standards
We hold the certifications that payers and auditors look for, and our coders carry the right credentials. It’s not the most exciting part of the work, but it’s the part that keeps your claims on solid ground.
Explore Frequently Asked Questions
The SNF billing process involves coding and billing claims for Medicare under the Patient Driven Payment Model for the skilled nursing facilities. SNF coding and billing involves translating MDS assessments to case mix classifications that establish the per-diem rate.
The SNF coding and billing process starts after a 5-day PPS assessment classification of residents to case-mix groups that have PDPM. These case-mix groups establish the per diem payment for 5 components that vary throughout the stay in a predetermined schedule. SNF bills Medicare for the bundled service and manages the excluded services billed by other organizations.
The two terms are used interchangeably when searching online but refer to different coverage. SNF billing refers to the Medicare certified skilled care benefit governed by PDPM and Medicare Part A benefit period. On the other hand, nursing home refers to the broader category that covers custodial and long term care services that are generally covered by Medicaid.
The Medicare Part A coverage requires an inpatient hospital stay prior to admitting a beneficiary into the SNF. The Notice of Admission marks the beginning of the benefit period used for billing. After that, the MDS assessment schedule provides the clinical information needed to determine the case-mix classification under PDPM and the per-diem payment.
Under a Part A stay, the SNF must bill Medicare for all services except those of an excluded category list. There are exceptions where the SNF must pay some other parties first. For example, there are many other services provided by providers outside the SNF who must be reimbursed first.
SNF billing uses the nation-wide PDPM per-diem rate based on case-mix classification derived from MDS. Medicaid billing of nursing facilities uses case-mix and rate methodologies specific to the state program. A single nursing facility may be billing both programs requiring the tracking of two different rates for the same residents.
Ultimately, the key question becomes how accurate PDPM will remain in light of staffing changes and gaps in coverage. The in-house option has its billing expertise, along with associated costs for hiring and training. In contrast, the outsourced option has the classifying and denial review handled by a team that processes SNF claims on a regular basis. Ultimately, the cost is based on census rather than personnel.
A skilled nursing facility registers as an institutional provider of Medicare services using the CMS-855A form. After that, periodic revalidation and change-of-ownership forms are necessary. Medicare Advantage plans and Medicaid have their own registration list, to which the facility must also register.