Welcome to The Billers' Association For Long-Term Care

The Billers’ Association for Long-Term Care is a membership community created specifically for long-term care billing professionals. This national association provides members with a resource of continuously updated tools, billing-specific education, and reimbursement and regulatory guidance. Become a member today and join your long-term care billing colleagues as you navigate the evolving world of post-acute care billing.

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Featured Article

What to do when you are under medical review

October 13, 2017
 | 
The Bottom Line

The main piece of legislation that guides the medical review (MR) process is Section 1862(a)(1)(A) of the Social Security Act, which states, “no payment may be made under Part A or Part B for any expenses incurred for items or services which … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed or missing body part.” If a medical reviewer or clinician denies a claim, the claims are denied based on this authority.

 

News & Analysis

What to do when you are under medical review

October 13, 2017
 | 
The Bottom Line

The main piece of legislation that guides the medical review (MR) process is Section 1862(a)(1)(A) of the Social Security Act, which states, “no payment may be made under Part A or Part B for any expenses incurred for items or services which … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed or missing body part.” If a medical reviewer or clinician denies a claim, the claims are denied based on this authority.

 

FAQs: Consolidated billing for SNFs

October 13, 2017
 | 
Billing Alert for Long-Term Care

Since its introduction in the skilled nursing facility (SNF) setting, consolidated billing (CB) has been one of the most routine yet misunderstood methods for SNFs to secure Medicare reimbursement.

To better grasp the complex principles, regulations, and systems that surround consolidated billing, SNFs must first have a solid foundation in Medicare Part A coverage and criteria. Without a basic understanding of this powerful insurance plan, SNFs risk committing or contributing to a number of punishable payment offenses, including improper billing, over- and underpayments, fraud, and abuse-related Medicare infractions that can carry serious ramifications, including steep penalties, exclusion from the program, imprisonment, or any combination thereof. 

 

The below Q&A contains questions that have been transcribed from our live webinar show, “Consolidated Billing for SNFs: A Close Look at the Five Major Categories,” hosted by expert speaker Janet Potter, CPA, MAS, senior manager, advisory services for Marcum LLP, and from frequently asked questions included in Potter’s new book, Medicare Guide for SNF Billing and Reimbursement. For more information on CB for SNFs, listen to the on-demand show or purchase our newly released Medicare billing guide.

The essential role of MDS 3.0 in RCS-1

October 6, 2017
 | 
Billing Alert for Long-Term Care

Currently, Medicare pays for services provided by skilled nursing facilities (SNF) under the Medicare Part A SNF PPS benefit on a per diem basis using the RUG-IV grouper. The most significant driver of this reimbursement model is the amount of therapy (days and minutes) provided to a Medicare resident, regardless of outcomes achieved. Through the years, many providers, government entities, and advocacy groups alike have voiced concerns over inappropriate incentives in this current reimbursement model. Caregivers of all types complained about a system that “de-incentivizes” an individualized approach to therapy treatment. Nurses felt their residents’ care was usurped by a system that didn’t consider their overarching needs. Not surprisingly, this led to overutilization; CMS estimates that in 2016, 11% of Medicare fee-for-service (FFS) dollars were paid incorrectly ($41.1 billion), with $2.8 billion of that amount being paid to SNFs for services almost entirely related to therapy.

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