Skilled nursing facility billing is the process to submit claims for specialized nursing, and rehabilitation services given to the patients. This process is performed mainly through Medicare Part A. It involves consolidated billing, which is a bundled payment system where the SNFs act as a central billing entity for most services. There are basically five key aspects of the SNF billing process which include consolidated billing, excluded services, reimbursement method, part B billing, and the role of staff. The billing process is a highly complex affair as it involves complex codes and modifiers. As it becomes difficult for the healthcare staff to juggle both administrative tasks and patient care, this is why it can be a feasible option to outsource skilled nursing facility billing solutions in that matter.

Challenges Faced by Skilled Nursing Facilities

The SNF billing process includes several underlying challenges which can affect the clinic’s revenue process significantly. Understanding these challenges is an important step to make sure no claim denial occurs.

Complexity in the Consolidated Billing Process

Consolidated billing is a complex regulatory requirement where the skilled nursing facility is responsible for billing Medicare for most of the provided services during Medicare Part A stay. It becomes difficult to know which drugs are included inside the bundle and which are excluded. For instance, some of the chemotherapy drugs are excluded and many non-chemotherapy drugs are included but it is a difficult process to identify them. Moreover, the billing staff need to differentiate amongst services falling under the SNF bundle and those which are separately payable by Medicare Part B. Hence, this is why this consolidated billing process is a very complex affair to take note of.

Coding and Documentation Errors

Improper coding and documentation can lead to significant revenue loss, and claim denials. While the industry has shifted to the Patient-Driven Payment Model, the focus has moved to increasing clinical complexities. The incomplete medical records fail to support all the assigned diagnosis. Moreover, there are also upcoding and downcoding issues where you use the wrong codes instead of the correct ones. Incorrectly using the modifiers to indicate the distinct services can lead to claim denial and lack of specialized training means that the in-house staff cannot stay updated with the evolving regulations.

Policy and Regulation Changes

The regulatory changes are one of the difficult challenges in the SNF billing process as it requires constant vigilance to maintain revenue integrity and compliance. The skilled nursing facilities are under heightened security for documentation accuracy, mostly in the post-pandemic era. Moreover, there is a triple check process used by Medicare which ensures that MDS assessments, billing codes, and clinical documentation match before a claim is properly submitted. The regulations occupying the 3-day qualifying hospital stay and a 100-day benefit period are highly complex. Most of the challenges occur when there is a change in the level of care which triggers a shift from Part A to Part B payment model.

Constraints in Staff and Resources

The staffing challenge leads to high claim denial rates, missed revenue opportunities, and compliance breach. As the SNF billing process needs proper knowledge of Medicaid, Medicare and consolidated rules of billing, a lack of trained staff can lead to cash flow crunches. The SNFs struggle to retain the experienced staff, and they need a nuanced understanding of all the CPT, ICD codes, and Medicare regulations. Undertrained teams fail to keep up with the shifting regulations and without a specialized staff, the clinics fail to conduct a proper follow-up which leads to claim denials.

Inefficient Accounts Receivable Management

The ineffective AR process is a major challenge in SNF billing, which results in high denial rates and proper revenue leakage. The skilled nursing facilities manage complex Medicare, managed care plans. Each payer has a different regulation, authorization needs and documentation standards which change mostly. Minor administrative mistakes, authorization lapses, or incomplete documentation leads to a higher rate of denial. The staff cannot prioritize all the aging claims properly by spending equal time on claims. Always remember that the longer the account stays unpaid, the less likely it is to be collected.

How Does the SNF Billing Services Help?

These third-party experts take several steps in accounts receivable follow-ups which include online and automated claim follow-ups. They can reduce your accounts receivable by 30% within a single month. These experts have expertise in working with difficult-to-recover aging AR and over 7 years of claim adjudication experience for major US insurers. They can reduce your operational costs by 80% and work with 10% buffer resources to make sure no issue occurs. Furthermore, these third-party companies also provide customized reports and the best infrastructure setup according to the client’s needs. You can expect to get a dedicated account manager, and they don’t have any restrictive clause or binding contract. In case any issue occurs from their side, they provide you with $1 million insurance coverage. So, if you want to streamline your billing process, it can be a feasible option to outsource SNF billing solutions in that matter.