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 House Committee Chairs Urge CMS to Update Consolidated Billing System

Two key House committee chairs have urged the Centers for Medicare & Medicaid Services (CMS) to streamline consolidated billing for post-acute care providers to improve the Medicare program for seniors, an effort that garnered praise from the American Health Care Association (AHCA).

AHCA Senior Vice President of Government Relations Clifton Porter II commended House Ways and Means Chairman Kevin Brady (R-Texas) and Subcommittee on Health Chairman Peter Roskam (R-Ill.) for their commitment to changing a system that has become outdated over the years.

“We appreciate the committee for recognizing the concerns related to consolidated billing. When the Prospective Payment System was initiated in 1997, the clinical complexity of our patients and residents was very different than it is today,” he said.

By encouraging CMS to update current standards relating to medication exclusions to be consistent with today’s patient needs, the two lawmakers are promoting both good public policy and improvements in patient care, Porter said.

“We thank Chairmen Brady and Roskam for their leadership and support,” he added.

The Balanced Budget Act of 1997 required that a skilled nursing facility (SNF) itself submit all Medicare claims for the services that its residents receive, a process known as consolidated billing. The billing method includes certain exclusion-of-care services not typically offered in a SNF, such as physician professional services, and allowed them to be separately paid under Medicare Part B.

SNFs are responsible for collecting these service claims and submitting a consolidated bill to CMS. AHCA said the intent by CMS was to prevent duplicative billing and to ensure SNFs coordinated care associated with patients’ care plans.

As the years passed, Congress and CMS have expanded the list of exclusions to include items and services that are not typically part of a SNF care plan. This ensures that a SNF is not required to absorb certain high-cost services and items that particular patients may need in rare circumstances.

Even though SNF care has modernized over the past two decades, Congress has not acted to expand the list of SNF consolidated billing exclusions since it passed the Balanced Budget Refinement Act of 1999.

That law put in place exclusions specifically defined into individual services within the categories of chemotherapy items and their administration, radioisotope services, and customized prosthetic devices, AHCA said. The law, however, gave the secretary of Health and Human Services the power to add new items and services within those categories.

But, AHCA said the lack of action at the secretarial level has resulted in a situation where it can be difficult for certain high-need, high-cost patients to be put in SNFs after a hospital stay. While SNF care has modernized this limitation makes it difficult for those advancements to be utilized.

AHCA has advocated for Congress to encourage CMS to update the consolidated billing exclusions within its current regulatory ability to help keep pace with the changes in health care delivery.

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