Petersen Health Care



Medicare and Medicaid ScreeningsIt is our policy that you request a Medicare screening for all new admissions entering the facility. The screening provides us with so much information, it is vital that we review the screening as a tool in determining the payer source for the resident and what benefits the resident may have. The screening is also a tool for monitoring Medicare Part B benefits and dollars in terms of therapy, therapy cap, and therapy thresholds. The screening can tell us:Resident benefits – if the resident has Part A, Part B, or both, or neitherHMO or primary insurance of some sort – Medicare will not pay the claim if an insurance policy is listed as primary. Contact insurance company to verify benefits and preauthorize if necessary.Hospice or Home Health billing dates – if dates overlap facility admission, Medicare will reject and we must contact hospice or home health company to change their billing dates. Medicare Secondary Payer (MSP) – Medicare shows another payer as primary, usually an insurance company. We must contact the listed primary and determine if any benefits are available. If not, we need to close the open MSP with letter of denial from insurance company.Go to the Petersen website to request the screening, see above. Fill in the resident information and submit. AR will then send you back an e-mail with information.Sample 1In this sample, the resident has Medicare A benefits effective since 1980. The last benefit period is shown, potentially with the 20 full covered days indicated in the SNF Full Days line and the 80 co-insurance days in the SNF Co Days line. As Medicare A billing is processed, the SNF Full Days set at 20 and are used until the remainder of the 20 days is 0, then the co-insurance days are counted down until the remainder is 0, at which point the resident would have no remaining days. THIS INFORMATION ONLY REFLECTS THE BILLING THAT HAS BEEN PROCESSED! Do not rely on this to determine your resident is admitting on Medicare Day1. Sample 2In this sample, the resident appears to have no remaining Medicare A days as indicated by the 0 in both the SNF Full Days and SNF Co Days. HOWEVER, notice the date of last billing! Medicare had not been billed for this resident since 2007. At this point, the facility needs to verify that the resident has had at least 60 Wellness Days since the last time on Medicare, and then proceed to examine the resident’s history over the last 90 days (at least) to determine which day of Medicare we might be starting on. Once Medicare is billed again, the system will reset showing the new benefit period and available days. Sample 3The screening indicates an effective date for Part B benefits. Benefits are then shown for Physical Therapy and Speech, which are lumped together in one category, and for Occupational Therapy. For Medicare Part B, the amount shown in the blanks is the amount of therapy dollars billed for the resident as of January 1st 2013. When you see a screening with $0.00 amounts shown, it means that no therapy dollars have been billed to Medicare. However, this only indicates the billing that has been processed – there could still be billing out there that is not reflected here! Sample 4This screening sample indicates that the resident had $291.69 worth of physical therapy and/or speech therapy charges billed to Medicare B during the year, and $130.29 worth of occupational therapy billed during the year. Therapy will want to review these amounts frequently to monitor when the resident reaches the “Therapy Cap” at $1920 and when a resident would reach the “Therapy Threshold” of $3700 for the year. At times we do have reason to bill therapy past the $1920 cap, but if we bill therapy over $3700 for the year, we will have to submit the medical records to Medicare to prove medical necessity before Medicare will pay. Sample 5The home office will also send you a sheet that looks like this – as an attachment on the e-mail with the screening form. Notice the line of this sample that begins “A-ENT 030191” This means – the resident has been entitled to Medicare Part A benefits since March 1, 1991. The next item on the first line says “A-TRM 000000” which would indicate a date the benefits terminated if they had – all 0’s indicates active benefits. You then see “B-ENT 030191” which means the resident has had Medicare Part B benefits since March 1, 1991 and then “B-TRM 000000” which indicates those benefits remain active and have not been terminated.This section indicates the Medicare Part A days remaining, and the date of last billing. In this example above, the resident seems to have 20 FULL-SNF days and 80 CO-SNF days (100 days) available as of 08142004 which is the date of last billing. However, this only indicates billing status – always verify to see the resident’s history of the past 90 days in case there is new recent billing not yet processed. Sample 6At the bottom of the first page you receive back on the screening, another thing the home office will report to you is if the resident has any HMO or Medicare Advantage Plan, as seen on the sample above. This information came from the Medicare system and can be seen as below:Particularly, notice the section in the middle:This indicates an insurance policy which is coded as H5421, and the home office looks up the code to give you name of the insurance company. This shows an enrollment date of 020107 and no termination date, which means the insurance policy is still effective. In addition, notice the Option code OPT C as seen above. Option codes for HMO plans which indicate whether the services are restricted or unrestricted:Valid Values1 = Unrestricted; intermediary to process all Part A and Part B provider claims2 = Unrestricted; HMO to process claims for directly provided services and for services from providers with effective arrangements. Intermediary to process all other claimsA = Restricted; intermediary to process all Part A and Part B claimsB = Restricted; HMO to process claims only for directly provided servicesC = Restricted; HMO to process all claimsThis is what the numbers or letters would mean under the option field if resident has an open HMO. Option C is one we see a lot! “Intermediary” refers to Medicare. You will also receive another page attached to your screening results that shows more details about the insurance including address and some policy info., such as Plan Type, etc:Sample 7At the bottom of the first page you receive back on the screening, another thing the home office will report to you is if the resident had any Hospice or Home Health services. Billing for these two entities can conflict with our Medicare billing and at times we need to ask them to close out their billing so that our Medicare claim can be billed. AR will put any Hospice or Home Health information at the bottom, as well as attaching the screen pages for these billers from the Medicare system – as seen below:This will be at the bottom of the attachment that is titled “Eligibility Check Report”You will also receive a screen shot from Medicare that looks like this sample:Home Health Care services will be shown in a similar way:Home Health billing could also potentially interfere with Medicare billing.Sample 8Another issue that might be encountered in a Medicare screening is called a “MSP” – Medicare Secondary Payer. Medicare shows another payer as primary, usually an insurance company. We are then alerted to complete/review the MSP Questionnaire with the resident or family and to contact the primary listed in Medicare to determine if there are any benefits available and if appropriate to do the Verification of Insurance, etc so that we can bill it correctly. For an MSP, Medicare may show you: effective date, MSP Code, Patient Relationship, policy number of the insurer, insurer information (such as name, address, employee ID, etc.). An MSP should lead directly to contacting the listed insurance company or other party listed to determine if there is any coverage available and the requirements for billing – completing the Verification of Insurance. MSP Value Codes and Associated Primary Payer CodesMSP Value codes are used to categorize the beneficiary’s claim into an MSP category once the primary payer is identified. They are also used to report on the claim the amount of the payment the provider received from the primary payer. The codes below are present on existing MSP files on the CWF (Common Working File).Value CodeDescription_____Primary Payer Code12Working aged (65+) with group health plan (GHP) A13End-Stage Renal Disease (ESRD) with GHPB14Auto or Other No-Fault (includes medical payment coverage)D15Workers CompensationE16Public health Services (PHS), government research grantsF43Disabled with large GHP – under age 65G41Federal Black Lung ProgramH42Veteran’s AdministrationI47LiabilityLAdmitting Residents with Open MSPs: If you admit a resident with an “open” MSP (there is an effective date but no termination date in Medicare), please be sure to do the research to determine if the listed MSP from the Medicare screening is the primary payer. We have seen admissions that had an open MSP and the nursing home stay was related to the MSP, but the resident was still admitted as Medicare A. If the resident is admitted with an open MSP that it UNRELATED to the nursing home stay – No-Fault (payer code D), Liability (payer code L), or Work Comp (payer code E) – these can be billed to Medicare A as long as there are no “trauma” type diagnosis codes or E codes. This includes not only the admission and MDS but also the therapy diagnosis codes! If a resident is admitted with an open MSP that IS RELATED to any of the above, they have to be admitted with the MSP as the primary payer, even if the insurance has exhausted. We have to bill the MSP insurance before any attempt is made to bill Medicare. If the resident is admitted as any other type of MSP, even if it is unrelated to the nursing home stay, the resident has to be admitted as PINS. We have to bill the MSP insurance and then proceed from there. ................
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