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August 2019

We’re making changes to the Medicare Advantage SNF post‑payment audit, recovery process

Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the post-payment audit and recovery process for its skilled nursing facilities. The changes will apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Here’s what you need to know:

  • Since June 1, HMS® no longer performs post-payment SNF audits for dates of service for Medicare Plus Blue claims. (BCN Advantage SNF claims haven’t been subject to post-payment audits.)
  • naviHealth will authorize Resource Utilization Group levels during the patient’s stay from preservice through discharge. This will be for SNF admissions with dates of service through Sept. 30, 2019. The company will work with SNFs to ensure that the biller submits the appropriate RUG level for reimbursement.
  • To align with the Centers for Medicare & Medicaid payment methodology, naviHealth will authorize Patient-Driven Payment Model, or PDPM, levels during the patient’s stay from preservice through discharge. This will be for SNF admissions with service dates on or after Oct. 1, 2019. The company will work with SNFs to ensure the biller submits the appropriate PDPM level for reimbursement.
  • On a quarterly basis, Blue Cross and BCN will review paid SNF claims to ensure that RUG or PDPM levels in the claims match the RUG or PDPM levels on the authorizations. If we find overpayments because levels on the claims don’t match those on the authorizations, we’ll pursue payment recoveries as necessary.
  • Providers won’t need to submit medical records during the quarterly post-payment review process.

Working with naviHealth

To ensure that SNF claims reflect the authorized RUG or PDPM level, work closely with naviHealth throughout the patient’s stay.

Keep the following in mind:

  • Before discharge, a naviHealth care coordinator will work with your biller to verify that the authorized RUG or PDPM levels are submitted for reimbursement.
  • If you have questions about the RUG or PDPM level that naviHealth authorized, contact naviHealth during the patient’s stay to resolve those questions.
  • When you submit SNF Medicare Advantage claims, make sure the RUG or PDPM levels on the claims match the levels on the authorization connected to the stay.

Additional information

As we communicated in an April Record article, naviHealth started managing authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For more details, see Post-acute care services: Frequently asked questions by providers.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.