TOP 10 MANAGED CARE & MSP SNF BILLING BATTLES

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1 WEDNESDAY, APRIL 16, A.M. CENTRAL TIME TOP 10 MANAGED CARE & MSP SNF BILLING BATTLES Manufacturing & Distribution Economic Update Julie Bilyeu Director BKD, LLP Lisa McIntire, CPA Senior Managing Consultant BKD, LLP To Receive CPE Credit Individual Attendee o Participate in entire webinar o Answer polls when they are provided Group Attendees o Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & address o All group attendance sheets must be submitted to training@bkd.com within 24 hours of live webinar o Answer polls when they are provided If all eligibility requirements are met, each participant will be ed a CPE certificate within 15 business days of live webinar 2 // experience clarity 1

2 Top 10 Managed Care & MSP SNF Billing s Payor coverage on admit Pre-approval process MA payment methods MA billing requirements MA compliance claims MSP plan types MSP conditional payment MSP electronic billing MSP claims coding Follow-up 3 // experience clarity #1 Identifying Managed Care & MSP Payor Situations Not identifying Medicare is secondary to another payor Not recognizing a patient is enrolled in a Medicare Advantage (MA) plan Confusing supplemental insurance with MSP or MA payor information MSP questionnaire Verifying benefits prior to admission Getting copies of cards for all payors 4 // experience clarity 2

3 #2 Pre-Authorization Not getting required preauthorization & subsequent authorizations Not understanding payor requirements for skilled care Claims not containing proper authorization numbers & date spans Documenting & tracking authorizations & reauthorizations Verifying payor requirements prior to admission Process for providing information to billing office 5 // experience clarity #3 MA Payment Methodology Not being aware that MDS assessments may be required Not understanding how an MA payor reimburses A/R misstated Not communicating cost share to patients upon admission Verifying prior to admission how a plan will reimburse Completing MDS assessments if in doubt Communicating prior to admission estimated patient out of pocket 6 // experience clarity 3

4 #4 MA Billing Requirements Claims reflecting accurate information as authorized by insurance Not billing claim correctly per contract requirements Timely filing requirements Tracking system for billing requirements by payor Understanding billing rules as stated in contract Timely filing parameters 7 // experience clarity #5 MA Compliance Claims Not recognizing need for MA compliance claims Not understanding purpose of filing MA compliance claims Staff education regarding CMS requirements Tracking system for filing & follow-up of MA compliance claims 8 // experience clarity 4

5 Pre-Admission Questions Is a contract required or will plan pay out of network? What is claims mailing address or electronic payor ID? What is patient s Medicare number for compliance claim purposes? Does payor require pre-authorization? Will subsequent authorizations be required? How will the plan reimburse, i.e., based on RUGs, daily rate, etc.? If the plan pays a per diem, will they reimburse additional funds for certain ancillaries? 9 // experience clarity Pre-Admission Questions What billing requirements are outlined in contract? What are plan s timely filing limits? Are assessments required? Is a hospital stay required? What is estimated patient out-ofpocket expense? 10 // experience clarity 5

6 Claims Pre-Submission Review Checklist Is correct payor & policy number on claim? Are correct authorization numbers on claim for time period being billed? Does claim reflect correct occurrence span code for qualifying hospital stay requirement? Do diagnosis codes on claim correlate with those authorized? Does claim reflect accurate revenue codes for accommodation days? Does claim include accurate ancillary charges & meet plan requirements for itemization? 11 // experience clarity #6 MSP Plan Types Not understanding different types of MSP payors Certain MSP payors can limit reimbursement Understanding what type of MSP plan you are dealing with Understanding payment limits for MSP payor 12 // experience clarity 6

7 #7 MSP Conditional Payment Understanding when it s permissible to bill for conditional payment Lack of processes to follow up & track potential conditional claims situations Education on requirements for filing for conditional payment Tracking system to trigger filing after 120 days from date of service 13// experience clarity #8 MSP Electronic Billing Requirements Not having a software system that creates MSP electronic files Limited by CMS electronic filing regulations MAC limitations with understanding MSP requirements Utilizing available software resources for MSP electronic filing Staff education on MSP filing requirements Developing MAC contacts for MSP claims handling 14 // experience clarity 7

8 #9 MSP Claims Coding Not understanding when you need codes Not understanding situational nature of billing codes Not updating coding for subsequent claims Staff education Cheat sheet for coding 15// experience clarity MSP Claims Coding Liability Liability Liability MSP Category Condition Code Value Code Occurrence Code Payment Received 47= amount paid 03= date of MSP record Payment Denied Liability 47= No response received-conditional Payment 47= = date of MSP record 24= date of denial 03= date of MSP record 24= date of last contact with payer 16 // experience clarity 8

9 MSP Claims Coding Disability MSP Category Condition Code Value Code Occurrence Code Payment Received Disability 43= amount paid 44= amount of contractual obligation if applicable Payment Denied Disability 43= = amount of contractual obligation if applicable 24= date of denial 17// experience clarity MSP Claims Coding Working Aged MSP Category Condition Code Value Code Occurrence Code Payment Received Working Aged 12= amount paid 44= amount of contractual obligation if applicable Payment Denied Working Aged 12= = amount of contractual obligation if applicable 24= date of denial 18// experience clarity 9

10 MSP Claims Coding No Fault No-Fault MSP Category Condition Code Value Code Occurrence Code Payment Received 14= amount paid No-Fault 44= amount of contractual obligation if applicable 02= date of MSP record Payment Denied 02= date of MSP record No-Fault 14= No response received-conditional Payment 24= date of denial 14= = date of MSP record 24= date of last contact with payer or attorney 19 // experience clarity MSP Claims Coding Workers Compensation MSP Category Condition Code Value Code Occurrence Code Payment Received Worker's Compensation 15= amount paid Worker's Compensation Worker's Compensation 44= amount of 02= condition is related contractual obligation if to employment applicable 04= date of MSP record Payment Denied 02= condition is related to employment 15= No response received-conditional Payment 04= date of MSP record 24= date of denial 04= date of MSP record 02= condition is related to employment 15 = = date of last contact with payer or attorney 20 // experience clarity 10

11 #10 MA & MSP Claims Follow-Up Paper submission to insurance payors Lacking a good tracking system for follow-up notes Keeping up with timely filing regulations Not reaching out for assistance Obtaining a vendor for electronic claims submission Establishing processes for tracking follow-up notes Understanding timely filing Reaching out to provider representatives, insurance commissioner, CMS MA Division 21 // experience clarity RESOURCES Benefits Coordination and Recovery Contractor (BCRC) previously (COBC) Phone: Address: MSP General Correspondence P.O. Box , Oklahoma City OK Link to CMS Regional Contacts Information/RegionalOffices/index.html?redirect=/regionaloffices/ Link to CMS MSP Manual Only-Manuals-IOMs- Items/CMS html?DLPage=1&DLSort=0&DLSortDir=ascending 22 // experience clarity 11

12 RESOURCES Link to CMS MSP Fact Sheet MLN/MLNProducts/downloads/MSP_Fact_Sheet.pdf Link to recent Med Learns article on change from COBC to BCRC MLN/MLNMattersArticles/Downloads/SE1416.pdf Link to Cahaba MSP Billing Guide 23// experience clarity Questions Julie Bilyeu, Director, BKD, LLP Lisa McIntire, CPA, Senior Managing Consultant, BKD, LLP // experience clarity 12

13 Continuing Professional Education (CPE) Credits BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars. 25 // experience clarity CPE Credit One CPE credit may be awarded upon verification of participant attendance For questions, concerns or comments regarding CPE credit, please the BKD Learning & Development Department at training@bkd.com 26 // experience clarity 13

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