North Carolina Hospice Providers Face Billing Scrutiny to Avoid Claim Denials
Hospice healthcare providers in North Carolina are being reminded of specific billing protocols for room and board services provided to patients in skilled nursing facilities (SNFs) to avoid claim denials, according to a notice from UnitedHealthcare Community Plan of North Carolina .
The core issue centers on duplicate billing, where both the hospice provider and the SNF submit claims for the same room and board services. This practice is leading to an increase in claim denials, incorrect payment rates and potential audit risks. The guidance emphasizes that the hospice provider is responsible for billing UnitedHealthcare on behalf of the SNF, and subsequently reimbursing the SNF a pre-negotiated per diem rate as outlined in their contractual agreement.
The Duplicate Billing Problem
UnitedHealthcare has observed a rise in duplicate claims, resulting in several negative outcomes. Claims can be denied outright due to the duplication. Alternatively, claims may be paid at incorrect rates, creating both contractual complications and increasing the likelihood of issues during audits. Incorrect revenue codes also contribute to claim denials.
Billing Structure for SNF Hospice Services
The North Carolina Department of Health and Human Services (NCDHHS) has established specific billing guidelines to streamline the claims process and ensure timely reimbursement. These guidelines cover both claims for room and board and claims for hospice services themselves.
Room and Board Claims
For room and board claims, the hospice provider acts as the billing entity, submitting claims to UnitedHealthcare Community Plan of North Carolina on behalf of the SNF. Billing is to occur monthly, utilizing the appropriate dates of service. Reimbursement from UnitedHealthcare is calculated at 95% of the SNF’s per diem rate, less any applicable patient monthly liability (PML). The hospice provider then reimburses the SNF at the rate stipulated in their contract.
Specific data entry requirements are crucial. The National Provider Identifier (NPI) for the SNF must be entered in the “Service Facility Provider” field, while the hospice provider’s NPI goes in the “Attending Provider” field. Revenue codes must align with the level of care provided, using 0658 for intermediate care and 0659 for skilled care.
Hospice Service Claims
The hospice provider also directly files claims with UnitedHealthcare Community Plan of North Carolina for the hospice services rendered. Reimbursement is made directly to the hospice provider. Again, the hospice provider’s NPI is entered in the “Attending Provider” field. Appropriate revenue codes, specific to the units of service administered, must be selected from a designated chart (the specific chart was not provided in the source material).
Broader Trends in Claim Denials
The emphasis on avoiding duplicate claims aligns with broader industry trends. UnitedHealthcare, effective , will be enforcing CMS and health plan guidelines by rejecting or denying multiple new claim submissions for the same date of service. Providers are instructed to submit a single claim encompassing all services rendered on the same date by the same healthcare provider.
corrected claims must replace the original entirely, and must include all previously billed services, not just the corrected line item. Failure to do so can result in overpayment recovery. Providers are advised to check claim status before resubmitting if payment hasn’t been received within standard processing times, to avoid creating duplicate claims.
Implications for Hospice and SNF Providers
These guidelines have significant implications for both hospice providers and SNFs operating in North Carolina. Hospice providers must ensure their billing departments are fully aware of the correct procedures for submitting claims on behalf of SNFs, paying close attention to NPI entry and revenue code selection. SNFs, while not directly billing UnitedHealthcare for room and board in these cases, need to maintain clear contractual agreements with hospice providers regarding per diem rates and ensure accurate record-keeping for audit purposes.
The increased scrutiny on duplicate billing underscores the importance of robust internal controls and communication between hospice providers and SNFs. Failure to comply with these guidelines could lead to significant financial losses due to claim denials and potential audit penalties. The guidance from UnitedHealthcare and the NCDHHS serves as a critical reminder of the need for accurate and compliant billing practices in the evolving healthcare landscape.
The focus on accurate billing extends beyond North Carolina. The National Government Services (NGS) Medicare provides resources on common hospice claim errors, highlighting the need for ongoing education and attention to detail in the billing process. While the specific errors cited by NGS Medicare were not detailed in the provided materials, the general principle of minimizing errors to ensure timely and accurate reimbursement remains universally applicable.
