Why did this happen? The patient was staying in a skilled nursing facility (SNF) at the time of her appointment—a stay that is covered through Medicare Part A. This is called consolidated billing, which is a prospective payment system that covers services within the scope of care at an SNF.
As a result, oncology practices can submit reimbursement claims through Medicare Part B only for those services that are excluded from the consolidated billing package.
Some chemotherapy is excluded from SNF consolidated billing, but other drugs are included. For example, interferon, methotrexate(Drug information on methotrexate), mesna(Drug information on mesna), leuprolide, and goserelin(Drug information on goserelin) (Zoladex) are included in SNF consolidated billing.
On the other hand, physicians’ professional services, such as all levels of office visits and most chemotherapy administration services, are excluded from SNF consolidated billing and are reimbursable directly through Medicare Part B.
But then administration of nonchemotherapy drugs and laboratory studies are included in consolidated billing and are reimbursable only through the SNF.
Confusing enough? Here are some simple things that you can do to keep SNF-related billing in order:
• Maintain an up-to-date list of drugs and services included and excluded in SNF consolidated billing.
• Determine whether a patient is an SNF resident at the time an appointment is scheduled.
• Educate patients, caregivers, and staff at local SNFs about the need to inform the practice about the patient’s status when making an appointment.
• Alert the SNF to charges for services included in consolidated billing before the services are provided.
• Continually monitor the status of invoices sent to SNFs and prompt as necessary.
• Establish written payment arrangements with local SNFs. Knowing which services are excluded from SNF consolidated billing and which are included is the most important step in ensuring appropriate billing.
