Other Healthcare Providers

Skilled nursing payment follows the days, the assessment, and the skilled need. Notes that repeat the same sentence do not show that need. Assisted living is not a Medicare skilled stay by another name. Long-term care files often contain a short Medicare skilled segment and a longer Medicaid residence. Appeal only the benefit that was actually billed.

Home health coverage generally requires a homebound patient, a skilled need, a practitioner’s care, and a plan of care, supported by a timely face-to-face encounter. Visits that happened are not enough if those elements are missing. Home infusion billed on the home health claim is a separate problem and is covered on the Home Infusion page.

An independent diagnostic testing facility may bill Medicare for the tests it is enrolled to perform, with the supervision those tests require. A new modality or a new site is not covered by last year’s enrollment. Calling the site a physician office on the claim does not change that.

Sleep centers get denied when an attended study is billed without a reason the patient could not complete a home test, or when the order does not match the study. DME suppliers get denied when the order, the coverage criterion in the medical record, and proof of delivery do not agree. The supplier can collect the clinical record. It should not invent it.

A rural health clinic is paid an all-inclusive rate for a qualifying visit, not a fee for every office code. Billing as if the conversion never happened is how the first probe starts. The practitioner who furnished the visit has to be one the rural-health benefit allows.

A PACE organization is paid capitation to furnish the services in the participant’s plan of care. There may be no claim to appeal. Billing companies are not the provider until the services agreement says they may speak for the provider. Answering an audit in the client’s name, or continuing a coding pattern the company knows is unsupported, is its own decision.