Medicare Basics: Overview of Medicare/SNF Benefit

• Eligibility Requirements for the Four Parts of US Medicare System
• Technical Eligibility/Skilled Coverage
• Compliance with daily skilled therapy and nursing need
• Direct and indirect skilled nursing services

PPS System: Bundled services/Components of daily rate

• PPS Schedule and billing cycle by type of assessment
• Financial penalties for non-compliance with PPS Schedule
• Setting the ARD to capture care provided for optimal reimbursement rates
• How special circumstances may alter assessment schedule and reimbursement levels
• HIPPS codes
• MDS Corrections policy – effect on billing

RUGs – III: RUGs 53

• Detailed explanation of which MDS elements comprise each of the 53 RUGs
• Index maximizing vs Hierarchy of RUGs
• Computing ADL Score and its effect on all RUGs
• MDS coding for delivered therapy
• Therapy minutes management to ensure correct reimbursement levels

Medicare Medical Review Process

• Responding to “additional development requests, provider appeals, and the Medicare Appeals Process
• MAC, CERT, RAC, ZPIC
• Nursing and Therapy documentation to support skilled need and successfully undergo claims review

Medicare Part B Rehabilitation Services in a Skilled Nursing Facility

• Requirements for therapy delivery & documentation under Medicare Part B.
• Introduction to Part B therapy billing for Clinicians: Fee for service vs the Part A bundled rate; automated Pre-Payment Part B billing edits
• Therapy Caps

SNF Management Strategies

• Successful SNF Admissions Process.
• Ensuring appropriate utilization of Medicare Part A benefits by residents, to include recognizing the daily skilled need.
• Operational strategies to ensure the nursing facility receives appropriate reimbursement for the care and service provided, such as the PPS meeting, Medicare QI meetings, Audits.
• Management considerations for delivery of Skilled Rehabilitative Services: In-house vs out-sourced therapy, monitoring therapy compliance and productivity.

Consolidated Billing: Inclusions/Exclusion

• UB-04 for Clinicians
• Recognize the major categories of consolidated billing.
• Know how to determine if a service is included or excluded from consolidated billing.
• Strategies for managing Part A consolidated billing to prevent overpayment/unnecessary payment by SNF to outside providers of bundled services.

SNF Beneficiary Notice Initiative

• When notice is required in a SNF
• Two principle types of notices and appeals processes.

RUGs 66 & Other CMS Initiatives impacting the Skilled Nursing Facility in 2010 and Beyond

• SNF Final Rule for FY 2010:
• RUGS-IV for FY 11
• MDS 3.0 Related to RUGS IV for FY11
• Pay for Performance
• Post Acute Care Demonstration