Insurance & Reimbursement

CLICK HERE for a copy of an ABN Form in Spanish.

Skilled Nursing Facilities (SNFs) must issue a liability notice to Original (fee for service) Medicare beneficiaries before the SNF provides:

  • an item or service that is usually paid for by Medicare, but may not be paid for in this particular instance because it is not medically reasonable and necessary, or custodial care.
  • For Part A items and services: SNFs may use either the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or one of the five SNF denial letters as the liability notice.

The following are examples of when a drug is not directly related or integral to a procedure, and does not facilitate the performance of or recovery from a procedure. Therefore the drug is not considered a packaged supply. In many of these cases the drug itself is the treatment instead of being integral or directly related to the procedure, or facilitating the performance of or recovery from a particular procedure.

There is a lot going on with the Healthcare Reform, Read here to see an over view of the topics published by Cigna Healthcare (Click Here)

Be sure you have office procedures in place to keep an eye on the time frame of your claims: Claims denied by Medicare for “untimely submission” are not eligible for appeal. In fact most carriers do not afford you an appeal if timely filing is an issue; there are only a few exceptions.  Timely Filing can have a significant impact on your Revenue.

Consolidated Billing (CB) is a requirement that places the billing responsibility completely on the SNF (Skilled Nursing Facility) for the complete care residents receive during a covered part A SNF stay.

There are a only a limited number of services specifically excluded from CB and are reported separately. For more information on Consolidated Billing including Excluded Services and Physician "Incident To" Services (Click Here)

NGS (National Government Services) has announced a Production Alert:

Therapy functional reporting claims may be rejecting incorrectly.

These are claims referred to in the MLN Article # SE1307, Outpatient Therapy Functional Reporting Requirements.  You can read more about about which claims are a part of the OP therapy functional reporting requirements (Click Here).

We all know how time consuming and costly COB (Coordination of Benefits) can be to a practice.   February 2014, CAQH launched a new plan called COB Smart Registry. This will help expand the communication between health care plans and providers. Joining with some Major Health Plans CAQH has come up with a solution to Improve Healthcare Claims Processes.

It is apparent as the healthcare changes so does Managed Care contracts.  You need to be more aware, they are more complex than ever and can be confusing, take heed as you enter into a new contract as a participating provider.  Below are just a few issues to be sensitive to and is in no way inclusive of everything you need to be aware of.

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