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The 1997 Balanced Budget Act (BBA) established that SNF consolidated billing is to cover the majority of services rendered during a resident’s stay for the first one hundred days (Medicare Part A). It also introduced a new bundled payment process that enabled facilities to consolidate and bill their services directly to the Medicare Administrative Contractor (MAC) for Part A. 

Calculating costs under the 1997 Balanced Budget Act for SNF consolidated billing.
SNF consolidated billing was introduced in the 1997 Balanced Budget Act.

Additionally, the BBA assimilated Consolidated Billing (CB) requirements, placing full responsibility on SNFs to submit all Medicare billing claims. This improved the billing process by eliminating duplicate billings and ensuring the coordination of care remains high.

There are, however, some specialized or costly services that are excluded from consolidated billing. These services are billed separately to Medicare and usually fall into the following categories:

  • Professional physician services
  • Certain dialysis-related services, such as ambulance transportation for dialysis services
  • Certain ambulance services, including the transportation to and from the SNF 
  • Certain chemotherapy drugs and administration services
  • Radioisotope services
  • Customized prosthetic devices

It can be confusing for healthcare providers to know which patients are approved in Medicare Part A SNF stays. Therefore, it is advisable for facility staff to first check with either the patient or their family members, which should be followed by visiting the CMS SNF webpage for further information. 

The Complexities of Medicare Skilled Nursing Facility Billing

According to Medical Billing and Coding, skilled nursing facilities must be certified Medicare Part A partners to qualify for Medicare skilled nursing facility billing. As for services rendered in uncertified nursing facilities, their bills are automatically sent to Medicare Part B (excluding therapy services). 

Doctor discussing the Medicare skilled nursing facility billing costs with patient.
Facilities must be certified partners for Medicare skilled nursing facility billing.

Since SNF consolidated billing was introduced, medical treatments given to Medicare qualified residents are bundled and billed together by the skilled nursing facility. Facilities must submit the claims by completing the CMS-1450 form or UB-04 form. The claims must be submitted every month to determine whether the resident is still applicable for Medicare coverage. 

However, medical billing can be confusing, primarily because forms must be processed by Medicare administrative contractors who follow a strict coding system. This means that facilities must complete the CMS-1450 form with complete accuracy. Incorrect Medicare codes can result in wrong reimbursement rates, with the facility or the resident bearing the brunt of the costs. 

For this reason, many nursing facilities include professional medical billers on their teams. These individuals specialize in sending accurate billing claims to the relevant government department. 

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How To Adhere to Nursing Home Billing Guidelines 

Financial managers are tasked with keeping track of hundreds of resident accounts and bill payors while also adhering to nursing home billing guidelines. It is, then, imperative that facilities find a means by which they can streamline their integrations with configurable data management and personalized billing settings. This can save them time and money while improving the accuracy of their financial data for the purpose of SNF consolidated billing.

Many administrators struggle to stay on top of their financial billing processes due to the complexities of Medicare skilled nursing facility billing. That is why so many organizations have recently invested in long term care EHR. 

Calculating medication costs that adhere to nursing home billing guidelines.
Financial managers must adhere to nursing home billing guidelines.

Long term care software can manage SNF consolidated billing through “profile windows” that process high volumes of data such as rules on payor plans and residents’ coverage. This enables facilities to use the AR-Billing feature to process profile rules while the eMAR software automatically generates claims according to a facility’s needs and preferences.

Some of the ways by which nursing home software helps administrators adhere to billing guidelines include:

  • Automatic billing to general claims
  • The ability to produce bills for groups of residents
  • Coordination of benefits among multiple payors using templates for reimbursement profiles
  • Streamlined Medicare billing to track length of stay and leaves 
  • An eligibility Interface to send real-time queries about a resident’s eligibility for Medicare, Medicaid, or other providers
  • Revenue cycle management to ensure regulatory compliance.

For further guidance, nursing facilities can refer to this Medicare skilled nursing facility billing manual to understand government requirements better and learn how to integrate long term care software into their financial management.

Benefits of SNF Consolidated Billing

There are ample resources that can aid financial billing and management. SNF consolidated billing may seem complicated, but the process is made far easier by way of integrating an efficient long term care software. A long term care EHR improves efficiency for both financial billing and on the clinical side; studies show that nursing home management software improves the quality of care, clinical documentation and decision-making, and financial management while reducing medical errors. 

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast

Cindy Wong
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