Consolidated Billing for Long-Term Care

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Consolidated Billing for Long-Term Care

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Consolidated Billing for Long-Term Care

Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC

Consolidated billing remains a constant challenge for compliance and billing long-term care professionals. Consolidated Billing for Long-Term Care helps skilled nursing facilities (SNF) figure out which billed services they are responsible for paying and which they are not.

This book opens with helpful background information on the intersection of SNF services and billing. It then covers the five major categories of consolidated billing and all the service inclusions and exclusions that apply to each, with an entire chapter dedicated to dissecting the trickiest cases. Also detailed is how to determine which components of an invoice should be paid and how to develop airtight payment agreements with outside service partners. Finally, this book provides strategies for implementing and shaping industry-required compliance systems (i.e., compliance and ethics programs and QAPI) that promote successful consolidated billing.

Included are case scenarios and figures to illustrate key concepts, tips on avoiding fraudulent practices and other common billing pitfalls, and guidance on obtaining appropriate reimbursement.

This resource will help you to do the following:

  • Apply expert insight and insider tips to your SNF consolidated billing
  • Understand what is excluded and included under consolidated billing
  • Improve workflow and financial viability with compliant consolidated billing practices
  • Avoid auditor scrutiny by correctly submitting claims to Medicare on the first try


Table of Contents

Part I: Background and Regulatory Breakdown

  • Chapter 1: The Basics of SNF Skilled Coverage
    • Medicare General Program Benefits
    • Skilled Services Defined
    • SNFs and NFs Defined
    • Reimbursable SNF Services
    • SNF Payment Coverage Requirements
    • General SNF Payment and Billing Requirements
    • Bottom Line
  • Chapter 2: Introduction to SNF Consolidated Billing: The Mechanics
    • A Checkered Billing Past
    • Consolidated Billing Defined
    • SNF CB Coding Requirements
    • First Look: Sample CB Claim Form
    • Termination of the Consolidated Billing Requirement
    • Bottom Line
  • Chapter 3: The Five Major Categories of Consolidated Billing
    • Excluded Services Defined
    • Major Categories of Consolidated Billing
    • Bottom Line
  • Chapter 4: Consolidated Billing Illustrated
    • CB Reference Charts: The Who, What, and When of Consolidated Billing
    • Test Your Knowledge: CB Fact vs. Fiction
    • Bottom Line
  • Chapter 5: Navigating Special Billing Cases
    • Categorical Exclusions
    • Ambulance Services
    • Physician and Nonphysician Practitioner Services
    • Unique Billing Scenarios
    • Leave of Absence
    • Chemotherapy Administration
    • Influenza and Pneumococcal Pneumonia Vaccinations
    • Bottom Line


Part II: Compliance Strategy

  • Chapter 6: Forging Successful Payment Arrangements With Outside Service Partners
    • Agreements and Notifications Defined
    • Rundown of the Payment Arrangement Provision
    • Sample CMS Agreement and Notification Letters Decoded
    • Bottom Line
  • Chapter 7: Best Practices for Ongoing Consolidated Billing Compliance
    • Billing Stage–Specific Compliance Strategies
    • Systemic Compliance Programs
    • Putting It All Together: Consolidated Billing Case Studies
    • Bottom Line


Appendix: Key Acronyms Defined


Who should read this book?

  • Billers coders
  • MDS coordinators
  • Administrators
  • Business office managers
  • Floor nurses
  • Directors of nursing


About the Author

Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC, is a regulatory specialist with more than 25 years of experience in the healthcare industry. She is the author of HCPro’s The QIS Mock Survey Guide, The Medicare Billing Manual for Long-Term Care, The Complete Guide to Long-Term Care Medicare Billing, QAPI: A Nursing Home’s Guide to Implementation and Management, Dementia Care: A Handbook for Long-Term Care, and Caring for the Dementia Resident: Ensuring Regulatory Compliant Care, as well as TrainingInMotion.org’s Carmelina: Essential Nursing Systems for Long-Term Care. As the founder of TrainingInMotion.org and instructor for HCPro’s Boot Camps, she is a nationally recognized trainer and speaker, advising long-term care organizations in regulatory compliance and how to maintain excellence in their respective roles.


Published: July 2015

Page count: 178
Dimensions: 6x9
ISBN: 978-1-55645-827-9