Nursing Home Billing Guidelines

by | Nov 12, 2021 | Medical Billing

Nursing homes are as important as hospitals and other centers of medical care nowadays. They are an equally important factor for ensuring the good health and wellness of citizens of modern American society. This applies more to the infirm and the elderly.

There are different types of nursing homes like skilled nursing facilities (SNFs), Independent Living Facilities, Assisted Living Centers, to name a few. These institutions bill their patient or the patient’s legal appointee for their services. The State has put some guidelines in place for such billing.

Let’s see what these nursing home billing guidelines are and which factors affect the billing process.

Period of Coverage of Bill

The nursing home usually issues a monthly bill for its residents for services it has rendered and medical care it has provided. The resident (or their legal appointee) enters into a contract with the nursing home. This contract offers details about billing frequency.

Mainly, this bill includes the charge of all essential services provided. However, sometimes, it also includes the charge of other associated services.

The billing cycle is the time period (calculated as the number of days – a month, for example) for which each billing takes place. Then, the nursing home may also charge a prorated amount for the month of admission. This means that in case the resident did not start his stay on the first day of the billing cycle, the billing amount equates to the per-day charge of room and board multiplied by the number of days. Sometimes, the care facilities also issue a pre-bill for the cost of the upcoming month.

Level of Care Provided

Assisted Living Centers like nursing homes and SNFs provide different, multiple levels of care based on the requirement of their inpatients. This level of care affects the amount they bill their patients to a significant extent. Further, these levels can broadly be classified into primary, secondary, tertiary, and quaternary levels of care.

A primary level of care provides the very essentials or the basic level of medical care. So, routine testing of a patient’s vitals falls under primary care. Additionally, if you require other specialized doctors to treat you, the primary level of care undertakes this required coordination.

Then there is the secondary level of care. Medical specialists usually provide this level of service. As an example, the primary care physician might treat a resident for common indigestion. But when the physician refers them to a gastroenterologist for further gastro investigation, it becomes the secondary level of care.

Tertiary care is very high, requiring complex equipment and a high degree of medical expertise. Some examples are complex microsurgeries and neurosurgeries. Tertiary care, being complex in nature, is not provided at small, regular hospitals or nursing homes. The nursing home usually refers its patients to specialized tertiary care centers.

Lastly, there is quaternary care which is nothing but an extension of tertiary care. It is a highly specialized level. Experimental cancer trials are an example of this.

Nursing Home Billing Guidelines

Type of Insurance Coverage

There are some Medicare Part A criteria for SNFs. If the medical needs of the patient in question meet these criteria, Medicare as an insurance carrier will pay for up to 20 days of stay in the nursing facility. Some insurance policies cover long-term care in nursing facilities.

Leaves of Absence

This is a factor that also affects the nursing home bill. A resident might need to leave the nursing home for a while. Mostly, they or their proxy will sign the bed hold waiver to reserve their room for them in their absence.

But this implies that the care facility will continue to bill the patient in his absence too. Alternatively, the inpatient could forfeit the bed hold, meaning fewer charges but nonavailability of room as a possibility when the resident returns.

The US Government has also specifically created and issued nursing home billing guidelines for nursing home billing. There are also CPT codes for nursing homes that simplify the billing process. For more information, you can visit Medical Healthcare Solutions, Inc.

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