These 3 Common Healthcare Admissions Mistakes May Be Occurring Daily in Your Skilled Nursing Facility:
1. “Skilled” Patients Being Admitted as “Custodial” Following a Hospital Stay
When the hospital needs to authorize the return of a previous resident of your facility, you may feel that you should do whatever it takes to allow the patient to return. After all, your facility has been his/her home for the past few months (or years) and it is where he/she has been most comfortable. However, it’s imperative to check your facility’s HMO contract prior to admitting anyone, even a long-term resident of your facility, to ensure that it includes a “skilled” benefit.
If the patient is classified as needing “skilled” treatment, you cannot admit him/her on a Custodial plan, regardless of whether you may plan to provide the “skilled” level of treatment.
As per CMS regulations, billing someone under a level different than what they are actually receiving (whether higher or lower) is illegal. If you don’t have the “skilled” contract, you will have to refuse the admission.
2. Rejecting Admissions Unnecessarily: High-Cost Admissions Can Still be Profitable
You want to admit as many referrals as you can and fill your facility’s beds; but many times, the projected expenses of the patient’s care seem to outweigh your room and board rate. You may feel that it will be more profitable to deny an admission based on high cost needs, be it expensive drugs or wound therapy.
However, it’s important to do due diligence before denying any admission. Research each case and never take the numbers at face value. Are there carve-outs you can utilize to offset some of the high expenses? Does your contract with this specific payer allow for any exclusions for high-cost drugs or lab? Pre-negotiating good contracts with each payer that include the common carve-outs and exclusions will allow you to accept even high-expense patients.
3. Mistaking an HMO Community Medicaid Admission with an HMO MLTSS Admission (Even if they are both Long Term)
Be on the lookout for Community Medicaid admissions, as you’ll need to be prepared to stay on top of many aspects of the patient’s billing process. Many times, a facility will automatically admit a Medicaid member and make the mistake of assuming they can easily obtain an authorization, as with an MLTSS member. The authorization process for Community Medicaid is a bit more time consuming .
You’ll also need to make sure your facility is contracted properly with the payer for Community Medicaid as opposed to LTC Medicaid. And of course, make sure you have a plan in action to move the patient to a Long-Term product so there will be no lapse in coverage.
A substantial percentage of admission mistakes are potentially avoidable. Being aware of these small details can go a long way in increasing your daily census and overall reimbursement.
LTC Contracting’s specialists are trained to assist your newly acquired SNF in obtaining and negotiating a favorable deal with the insurance company, whether it be a Commercial, Managed Medicare, or Managed Medicaid plan. For a professional review of the Medicaid/Medicare billing options for your newly acquired SNF and for any other related information, contact us at LTC.