Admissions is not a person. Admissions is not a department. Admissions is a process. With an increasing regulatory environment and scrutiny by payers regarding claims submitted, it is ever important for Skilled Nursing Facilities (SNFs) to have a structured Admissions process. A structured Admissions process is fundamental to successful Accounts Receivable Management. Successful Accounts Receivable Management helps to ensure positive cash flow to fund the payroll and programming goals for the facility. Quality care and innovative programming require a positive cash flow.
The Administrator of the SNF can be the catalyst to shift the relationship between departments from a "That's not my job or That's the job of the ________ department" to an integrated and truly inter-disciplinary approach to the Admissions process. Facility leadership/ownership must set the expectation that all departments will cooperate with one another to achieve the ultimate goal of Quality admission for the resident and family. If all departments work together in tandem, the result can yield increased communication and teamwork and better financial outcomes. These include "clean claims", lessened risk for ADRs and potential negative outcomes resulting from audit oversight. Audit programs such as CERT, ZPIC, RAC are reviewing claims both pre and post payment. These programs are looking for improper payments and any possibilities for fraud and abuse. Administrators/Owners can not minimize this issue, presuming that fraud and abuse could not happen at their facility. From the perspective of the audit programs, fraud is viewed as intentional and abuse is viewed as unintentional. Human error falls into this category. Lack of training or failure to keep current with the latest regulations regarding billing can set the stage for human error.
To help establish and maintain the best platform for successful a Admissions process, consider these Best Practices for the continuing care industry:
Establish an Admissions team. It can serve as a Pre-Admissions Review Team as well as a Triple Check Review team just prior to claims submission to Medicare and third party insurance carriers. The Admissions Team should include Admissions, Social Services, Therapy, DON/ADON- MDS, Business Office and any others who may play a vital role in the facility decision making process.
Obtain insurance information and verifications for all admissions. Get copies of all insurance cards. Date the copies. Contact carriers to verify coverage, co-pays, limits and requirements for authorizations and certifications for care and services provided. Be sure to understand the process, address and claims submissions process for payers. Some payers require pre-authorization followed by a call within 24 hours following admission. Residents may have multiple cards in their wallet/handbag, necessitating that verification of coverage is done to ensure that the proper payer is identified and billed.
Educate all Admissions Team members about the requirements for skilled care coverage under Medicare, especially for Part A admissions. Be sure that assessments, evaluations and decisions meet requirements for medical necessity and documentation of services.
Educate Admissions staff on regarding verification of hospital admissions vs. observation stays.
Complete a Medicare as Secondary Payer (MSP) for ALL admissions, not just Part A.
Discuss financial expectations with residents/family prior to or at the time of the admission. Private statements are mailed the last week of the month, payments are expected by the 5th-10th day of the month. The facility will bill Medicare, Medicaid and third party carriers on behalf of the resident but that is not a guarantee of payment. Residents/family are expected to cooperate fully with requests for information, applications and review, etc. The facility will assist but will expect residents/family members to work together to facilitate a timely process.
Pre-bill for all Private Pay residents. Medicare charges can not be billed until after services are delivered, however Private room and board as well as some ancillaries should be billed 30 days in advance. Medicaid patient liability can also be pre-billed. Set up ACH, credit card payment and other processes to make the payment process as easy as possible for residents/family members.
Offer to assist all residents who may be in the process of application for the Medicaid program. Become Rep Payee, complete the patient liability resource worksheets to determine monthly patient liability, offer to make copies, transport resident/family members to appointments with caseworker, offer to represent the resident at any meetings, etc. etc.
Be on the forefront of learning about the Medicare/Medicaid Managed Care plans in your area. Medicaid residents will need to make choices regarding available plans.
Complete the Advanced Beneficiary Notice (ABN) appropriately. It is not to be used for all admissions, only those for whom there is an expectation that the resident will have financial liability.
If the resident is admitting from a hospital based SNF or another nursing home, contact the provider to verify any Medicare Part A days that may have been used in the current benefit period. If the resident is receiving Medicaid, determine the patient liability for the month; obtain information regarding funds in the resident trust account, rep payee info, etc. Is the patient being discharged for non-payment?
Educate team members regarding completion of the MDS 3.0 questionnaire. Even if an MDS nurse handles the submission, all disciplines involved must tell the same story regarding care of the resident. Therapy services are a red flag risk area. It is critical that therapy staff understand therapy caps, medical necessity and appropriate documentation requirements to help minimize ADRs.
Implement the Triple Check process utilizing the Admissions Team to review a "charge to chart" review of claims prior to submission to carriers for payment. The Triple Check process should follow a checklist that addresses the top risk areas identified by the various audit programs such as CERT, ZPIC, RAC, etc.
The old days of strictly defined roles for each department in a SNF are long gone. Today's successful operator employs an integrated approach not only to the delivery of an inter-disciplinary team philosophy of care but also to the Admissions process. Cross training, communication and leadership will help team members to truly work together with a shared goal of created a positive admission experience for the resident/family and successful platform for payment for services provided. A quick turnaround of claims and payment supports a SNF provider's ability to support their mission of providing quality care and services.
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