A nursing home is a complex institution. A vast array of services is associated when you are dealing with a nursing home practice. Thus, nursing home facility billers need to understand the basics of billing requirements, the types of services associated with this type of facility, and the various aspects of billing relevant to this setting.

Common Questions Asked in Nursing Home Billing

When you are running a nursing home practice, the most common question asked is about the billing pattern.  

How frequently is the billing done – monthly, or weekly? And what is the nursing home facility fee?

The answer is not as simple as you think it is. When Medicare billing is insured for nursing homes, it operates on a monthly cycle. Providers submit a consolidated bill, which must include not only all the details of the care but also the specific services received by each resident for each billing cycle. Moreover, when you are dealing with a small, mid-size, or large nursing home billing company in the US, you must know that nursing home billings are typically all the same. Mainly, it involves monthly charges for services provided, including room and board, skilled nursing care, and ancillary services. At times, the billing process may also include prorated charges for the month of admission. Additionally, a pre-bill for the following month is also essential in some cases. Understanding the various components of the bill, including basic and ancillary charges, is necessary.

Here's a more detailed breakdown of the types of nursing home billing services across the US:

It is no secret that nursing home billing fees vary widely. It mainly depends on the level of care required, the type of room, and the location, among other factors, which become the deciding factors. However, below is the basic division of the different kinds of nursing home billing practices: 

The second common question that any nursing home practice faces constantly is,

How are these nursing home facilities billed?

It is no secret that dealing with a nursing home facility can be complex, as a resident does not enter the healthcare center on the first day of the billing cycle. Therefore a billers needs to focus on the first billing statement showing a prorated amount for the month of admission f the particular patient. Additionally, pre-bills may be expected at times. Furthermore, it is worth noting that the amount owed by the resident is calculated after accounting for payments made by Medicare, Medicaid, private health insurance, or long-term care insurance plans. 

How nursing home billing works:

Monthly billing - This is one of the most common types, where a resident or patient, or their legal representatives, are billed monthly for the treatment or services provided by the nursing home facility. 

Prorated charges—This occurs when a resident moves in or out during a month. Here, then, all the charges may be prorated based on the number of days spent in the individual facility.

Activity-based costing—Additionally, it is observed that nursing homes may utilize activity-based costing to allocate costs for various services and activities rendered to patients.

Consolidated billing - Skilled Nursing Facilities (SNFs) operate under a consolidated billing system. Though it may be confusing to many. This, however, means that certain services are included in the per diem payment, while others may be billed separately, as per CMS.

Important considerations that you need to know in case of nursing home billing:

Medicare and Medicaid - Residents covered by both Medicare and Medicaid may undoubtedly receive overlapping coverage for services provided. Therefore, it becomes even more crucial to understand which services are eligible under each program. 

PDPM or Patient-Driven Payment Model - The PDPM is a Medicare reimbursement system that classifies patients into payment groups based particularly on clinical characteristics rather than therapy minutes. This PDPM model has reshaped how SNFs approach billing and documentation. 

Another frequently asked question in nursing homes is the type of codes.

Codes are one of the most confusing aspects of this practice. There are generally four types of codes associated with this. Starting from ICD-10 codes for all diagnoses, HCPCS codes, and, of course, CPT codes for specific procedures and services, as well as revenue codes for the type of service provided. Additionally, when coding for nursing home services, it is essential to remember that modifiers are used to add more detail to the billing codes, such as indicating a separate E/M service or multiple procedures.

What role do Medicare and Medicaid play in nursing home billing?

Medicare and Medicaid both cover many (and often all) of the services provided in nursing homes. Although there are specific rules about what can and can’t be claimed at particular times. However, many of these rules can be understood by looking at the eligibility criteria for Medicare Part A and Medicare Part B benefit periods.  

Also, remember that all the coverage and eligibility can vary significantly between plans. Therefore, it is advisable for providers looking for a seamless and successful nursing home billing operation to always be clear about long-term, SNF billing guidelines for patients who intend to use private insurance.

While unpaid nursing home bills can result in potential discharge, it is also essential to have the right operational team to handle these complications. Furthermore, with so many rules and complications along with high staff turnover, increased staffing costs, ongoing staff shortages, and, of course, declining reimbursement, there are providers looking for the option of outsourcing. Thus, today, more than 60% of such facilities are choosing RCM operations to manage their billing affairs.

SunKnowledge - a key to all your nursing home billing practices:

With over 17 years of experience in the industry, SunKnowledge offers unparalleled expertise in navigating the intricacies of nursing home billing, enabling facilities to streamline operations and enhance revenue outcomes. With a focus on providing comprehensive care for all such facilities, we are today recognized for delivering state-of-the-art solutions to numerous leading industry names. Taking care of all skilled nursing home billing, long-term care, and rehabilitation services, we are known for providing personalized care. Offering an accuracy rate of 99.9%, with our precise documentation, constant follow-up, and timely claims submission, you only have to spend $7 an hour for timely claims submission, better ROI, and dedicated assistance with your billing needs. Still confused? Reach out to our expert and change your billing operation within weeks with a no-commitment call.