Edition: Skilled Nursing

July 2024

Stay informed with the latest updates and hot topics in the managed care industry with our July newsletter. We are dedicated to keeping all providers informed of the ever-changing and evolving landscape that is managed care.

Happy Fourth of July!

Wishing everyone a day filled with joy, reflection, and a renewed commitment to building a brighter future. Here's to liberty, creativity and the pursuit of excellence!

Attention all providers!

Florida Blue Commercial providers may see requests for medical records in the coming months.  The request is part of the Department of Health and Human Services requirement for health plans to validate the accuracy of risk adjustment data submitted to the Centers for Medicare and Medicaid Services (CMS).

Individual and Small Group health plan markets will be the primary focus.

There will be multiple ways to submit this information to Florida Blue to include:

  • Remote access to your EMR
  • Secure File Transfer
  • Fax
  • Email (secured)
  • USPS Mail

If your organization receives a request for records, it is always advised to validate the request prior to submitting.

In the Skilled Nursing Facility world, billing can be complex. CMS regularly updates their codes and processes and some of the managed care plans adopt these changes, while some do not.  We frequently receive questions regarding consolidated billing and how it applies to managed care payers, Medicare Advantage in particular. In years gone by, Medicare Advantage (MA) plans did not always apply consolidated billing; even though some may have had it as a statement in the contract, it was not utilized by the plan’s claim department. As usual, nothing stays the same and the MA plans are now applying consolidated billing but still allowing exclusions for high-cost medications or special equipment within the contract.

With so many changes occurring, how up to date are you and your team on Consolidated billing? CMS makes frequent changes to their policies so there may be items now on the exclusion list that were not previously.  The following links will direct you to CMS’s most recent information SNF Consolidated Billing | CMS  Consolidated Billing | CMS Skilled Nursing Facility Billing Reference - MLN006846 (cms.gov)

As always, review your managed care contracts and consult your billing leadership for the most accurate information that applies to your situation.

Improper Diagnosis Codes Causing Claim Denials

Who determines the patient’s diagnosis codes when a patient enters your facility under managed care? Which codes are being used to obtain the authorization and are they really appropriate? If it is admissions, are they trained for this? Are they collaborating with nursing or MDS for appropriate codes?

Health plans are cracking down on inappropriate diagnosis codes and denying claims as such. All too often, we see claims denying because the codes utilized are not correct.

Example: S72.92XA “Unspecified fracture of left femur, initial encounter for closed fracture” would be used by the hospital and would likely be the diagnosis on the referral. However, a SNF does not do initial encounters; SNFs provide after care. Z47.89  “Encounter for other orthopedic aftercare” would be one of the choices as a more appropriate code for a SNF. It is important to validate what codes your team is using, not only the admission diagnosis, but also for submission of the claim. This is another reason why Triple Check for managed care is just as important as it is for Medicare.

Some things to think about - does your team do Triple Checks? Was there pushback from the team to include managed care? 

Are you an Aetna Better Health provider?  If so, your billing team may have received a special invite to test pilot a new tool on Availity starting in July. Aetna Better Health is looking to improve their claim dispute interface and process. The pilot program requires billers to sign up by June 19th but here is a preview of what is coming up.

Easier submission and tracking for claim disputes: Ability to submit the dispute directly from the Claim Status app in Availity, which will auto populate the provider’s information in the form. The new functions will also allow for easier uploading of documentation, validate duplicate requests, and view an audit trail. These new features and functions will certainly make the claims dispute process easier to work with.

How efficient and accurate is your team on diagnosis and claims coding? We recently posted that the health plans are starting to decline claims based on improper coding.

Simply Healthcare is offering free coding webinars for providers. Find the educational webinars here.

This is an easy way to provide education to your team.

Does your organization utilize the United Healthcare Provider Portal? If so, please note that United is making changes to the log in method and will require a One Healthcare ID sign in by summer of 2024. This means that if your do not have a One Healthcare ID, you will have delayed access to the portal until it is updated.  The One Healthcare ID adds an additional security layer to keep patient records secure.

For full details and how to update your sign-in settings, please visit Provider portal authentication | UHCprovider.com.

Reminder Kepro, the Quality Improvement Organization (QIO) Kepro BFCC-QIO (keproqio.com) is rebranding as Acentra Health. Same services and websites for now. Forms will be need to updated from Kepro to Acentra Health by fall 2024, allowing the use of Kepro on NOMNC, IM and other QIO associated form for now. Find the FAQ here.

Sunshine Health is offering a variety of billing and coding webinars to providers. It appears that they will be discussing ICD 10 Coding issues on some of the webinars. Incorrect and duplicate coding is causing a lot claims rejections from multiple health plans. To learn more about the webinars offered by Sunshine, please visit Sunshine Health Offers Free Webinars to Improve CDI, Coding Skills | Sunshine Health

Upcoming Conferences

Booth #103

Booth #501

Booth #324

Educational Webinars Hosted by MCCA


  • Most Expensive Mistakes hosted by: Chris Langebrake


  • Common Billing Errors hosted by: Chris Langebrake and Nita Bolton

Please reach out to your liaison for invitations to join.

Housekeeping Items

  • Verify benefits every 1st and 15th of the month as a best practice.
  • New employees, please let our liaisons know so we can setup training
  • Discharge Summaries should be sent to the health plans and patient's PCP upon discharge
  • Have you registered for our new portal? Register here!

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