Ask the Experts, News, Skilled Nursing Facility

Ask the expert: Medicare Advantage

Q: How do I know if my resident is Traditional Part A or has a Medicare Advantage Plan? My confusion comes into play when the Business office admits a Medicare Part A patient into our skilled nursing facility, but then I see copies of insurance cards that say Blue Cross Anthem, Blue Shield, Secure Horizons, AARP, ect. I am sending the RUG’s straight to Medicare for billing and not through to the insurance company. Is this correct?

A: Part 1: It’s important to discuss insurance options with the family, then, validate the information in the common working to know which type of insurance the patient has.  You can also check with the hospital’s billing department to see if they have any additional information.

Part 2: If the patient has Medicare Part A, then the RUG scores are submitted via the UB-04 to the MAC and the scheduled Medicare-only MDS is submitted to the ASAP system.  If the patient has a Medicare Advantage Plan (Medicare C), then an informational only (no-pay bill) is submitted to the MAC so the common working file can deduct the Medicare days from the total.  But it is the insurance company that will pay you and you need to abide by their contractual rules for billing.  The new rule that went into effect in July, regarding submission of a RUG score to the MAC is done with an OBRA assessment, which calculates the RUG score for the insurance company.  The insurance company in turn submits to CMS.