1. Solving the Mysteries of SNF Reimbursement
Juli Pascoe, CPA, Director
Julie Bilyeu, Director

2. Case #: 1
Disappearing Medicare Payments

3. The Investigation Leads:
The Evidence:
The Investigation Leads:
eligibility
The Informer: Administrator Frieda Krueger
The Scene: Elm Street Manor
The Mystery: The SNF has a large amount of uncollected Medicare balances.
Verification of _______ prior to admission & monthly for skilled residents
Confirm time & ____ of hospital admission
Claim status in the Medicare _____ system
date
DDE

4. Case #: 2
Puzzling Invoices

5. The Investigation Leads:
The Evidence:
The Investigation Leads:
The Informer: A/P Clerk Auntie Bee
The Scene: Mayberry Cottage Rehab & Nursing
The Mystery: Large hospital bills from Opie General that she is not sure the facility owes.
Verifying CMS major category ________ to determine responsibility
Have they negotiated ________ with outside providers/suppliers
Are ______ being sent to inform other providers when patients are in a covered stay
exclusions
contracts
notices

6. Case #: 3
Suspect Aging Report

7. The Investigation Leads:
The Evidence:
The Investigation Leads:
The Informer: CFO Cherry Pitts
The Scene: Orchard Heights Senior Care
The Mystery: A very large aging report that is full of suspect balances
Are Medicare A rates being updated _______ of each year
What is the process for 2% ___________ adjustments
Is ____ being reconciled monthly to the bank statement
October
sequestration
cash

8. Case #: 4
Inquiry Into Mass Recoupments

9. The Investigation Leads:
The Evidence:
The Investigation Leads:
contact
The Informer: DON Nancy Ratched
The Scene: Cuckoo’s Nest Senior Living Center
The Mystery: Received a letter noting a large recoupment pending from Medicare following post payment review.
Has facility _______ information been kept up to date
Who is responsible for notifying facility personnel & _______ therapy of pending review requests
Does the facility ____ the status of reviews & appeals
contract
track

10. Case #: 5
Disappearing Biller

11. The Investigation Leads:
The Evidence:
The Investigation Leads:
deadlines
The Informer: Fred Flop
The Scene: Vegas Skilled Nursing Center
The Mystery: His biller has disappeared & he doesn’t know what needs to be done & what steps need to be taken to ensure billing is completed this month.
Are there established ________ for when billing & month end should be completed
What _______ programs does billing use for billing, submitting claims & performing follow up
Is there a _______ plan
software
back-up

12. Case #: 6
Missing Accounts Receivable Benchmarks

13. The Investigation Leads:
The Evidence:
The Investigation Leads:
days
The Informer: Board Member Alan Sharpie
The Scene: Shady Pines SNF
The Mystery: The SNF is running dangerously low on cash & have had significant cash collections issues in recent years.
Average _____ to collect
Accounts receivable _______
Days ____ on hand
turnover
cash

14. Case #: 7
Payer Plots

15. The Investigation Leads:
The Evidence:
The Investigation Leads:
The Informer: Administrator Taylor Harris
The Scene: Friendship Harbor SNF
The Mystery: When should payers normally remit payment to SNFs?
30 Days – Private Pay, Medicaid, ________
60 Days – Medicare ___________, insurance
If using a _____________
90 Days – Medicare co-insurance, insurance
If filing paper claims
Medicare
co-insurance
clearinghouse

16. Case #: 8
Booking Bad Debt Expense

17. The Investigation Leads:
The Evidence:
The Investigation Leads:
co-insurance
The Informer: CFO Newbie
The Location: Bendy Oaks SNF
The Mystery: How much bad debt expense should a SNF book on a yearly basis?
Medicare ___________
Can be collected at a _________ percentage on the Medicare Cost Report
Occasional _______ balances
Bad debt expense as a percentage of ______________
Expect ½% - 2%
reduced
private
patient revenues

18. Case #: 9
Financial Statement Frame Up

19. The Investigation Leads:
The Evidence:
The Investigation Leads:
Revenues on financial statements = What you get ____.
Medicare – pays at _____ levels
Use payer logs or PSR to check amounts recorded
Medicaid – days X ________ rate
Private – Average per day amount should fall between private rates
Insurance – contract rate, __________ rate, RUG rate
The Informer: Chloe Lamar
The Scene: Calabasas Coves SNF
The Mystery: How should a person with a nonfinancial background review & have confidence that revenues are recorded correctly on a financial statement?
paid
RUG
per diem
level of care

20. Case #: 10
Accounts Receivable Surveillance

21. The Investigation Leads:
The Evidence:
The Investigation Leads:
aging
The Auditor: Fallon Kimmel
The Scene: Late View SNF
The Mystery: What could have helped Late View SNF avoid this large hit to the bottom line that was discovered during their year end audit?
Accounts receivable ______ review
What is it?
How often?
Ask _______ questions
Set _________
Follow established collections policy
specific
thresholds

22. The Future of Our Mystery Firm

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