Scrutiny of SNF Medicare Patient Transports

Transports of Medicare SNF patients will come under closer scrutiny as a result of a transmittal from CMS to Medicare contractors last week (http://www.cms.hhs.gov/transmittals/downloads/R595OTN.pdf).

An Inspector General Draft Report earlier this year found that on occassion, ambulance services were errantly paid under Part B instead of under the SNF Consolidated Billing Rules.

To prevent future occurrences of this, CMS has directed contractors to implement claim level edits to reject Part B ambulance claims that should have been billed and paid for according the the SNF Consolidated Billing Rules.

The transmittal specifies that ambulance claims shall be subjected to the following conventions:
"If a claim for a hospital outpatient service is denied because it should have been billed and paid for according to SNF CB rules, contractors shall deny any ambulance service associated with the denied hospital outpatient service as the ambulance transportation is also subject to SNF CB rules. Conversely, if payment for a hospital outpatient service is not bundled into the SNF CB rate and is separately payable under Part B, then the ambulance service associated with that service is also separately payable under Part B."

While the transmittal does not technically change the rules regarding services that are covered by SNF Consolidated Billing vs. Part B, this change may impact ambulance payments for a couple of reasons.

If you are improperly billing Part B for transports that are covered under SNF CB and have been getting paid, as the contractors implement the new edits, you will get denied, and will then have to bill the SNF.

It also appears that being paid under Part B will also be dependent on the billing of the outpatient service. Based on the wording of the transmittal, there is a cause-effect relationship between the denial of a hospital outpatient service and the denial of ambulance transport related to the outpatient service. From an implementation standpoint, this could result in delay of processing some ambulance transports to wait for the outcome of the processing of the associated outpatient service claims.

Alternatively, if ambulance claims are improperly billed to Part B, and are processed and paid before the hospital outpatient service claim is processed -- the new edits will likely trigger a payment Medicare payment takeback if the hospital outpatient service claim is later processed and denied because the service should have been covered under SNF CB.

The best way to minimize the impact of this increased scrutiny is to make sure that you understand which SNF related transports are eligible under Part B and which need to be covered by SNF CB and then bill accordingly.