How The Triple Check Process Ensures Billing Accuracy and Compliance

When it comes to billing in your skilled nursing facility (SNF) you have an expectation: bills consistently submitted on time with no errors. At times, this can be easier said than done. But a Triple Check Process in your facility can easily make “clean claims” a reality.

The Triple Check Process is an internal audit that ensures billing accuracy and compliance with regulatory guidelines prior to the submission of claims to Medicare/Managed Care providers for payment. It is a multi-level process, requiring a group effort from the Interdisciplinary Team (IDT) in order to provide a check and balance to the entire admissions, billing, and Minimum Data Set (MDS) process for Medicare/Managed Care residents.

To ensure you receive the best outcomes from your Triple Check Process, it should be completed around the eighth day of the month following the month you are closing. For example, closing for the month of June should occur around July 8.

When setting the specific date for your Triple Check meeting, it’s important that all MDSs are completed, submitted, and accepted for the closing of the month. When planning for your Triple Check meeting, don’t forget to include, at a minimum, your Administrator, Business Office Manager, DON/Medical Records, MDS Coordinator, and Rehabilitation/Therapy department.

In order to conduct your Triple Check Process properly, your team will need to review the following:

1. Therapy services documentation accuracy by:

• Ensuring medical necessity
• Ensuring appropriate supporting diagnoses
• Verifying that minutes/units reported on service logs are detailed properly on the claim
• Medicare Part A: minutes correspond with RUG designation
• Medicare Part B: units reported in compliance with regulation
• Verifying appropriate modifier usage (KX or 59)
• Physician order is for treatment provided and specific to services provided
• Therapy Plan of Care is signed and dated by physician

2. MDS by:

• Ensuring MDS assessments are completed, submitted and accepted for the current billing cycle
• Ensuring UB-04 and MDS match (diagnosis codes, assessment reference rates, occurrence dates, etc.)

3. Medicare compliance/clinical eligibility requirements by:

• Making sure the beneficiary needs and receives medically necessary skilled care on a daily basis, provided by or under the direct supervision of skilled nursing or rehabilitation professionals
• Skilled services are only provided in a skilled nursing facility setting
• Skilled services ordered and certified by attending physician
• Services provided must be for a condition for which the client was treated for during the qualifying hospital stay or arose while in the SNF for treatment of a condition for which the client was previously treated for in the hospital

4. Verifying physician certification/recertification by ensuring:

• Initial certification signed and dated by physician/NP/PA
• Cert/Recert is complete with all required information and signatures
• First recertification signed by the 14^th day by physician/NP/PA
• Subsequent recertification within 30 days of the previous signature by physician/NP/PA

*Note: Inaccuracy/incompleteness will cause an automatic denial during an audit with no appeal available

This process can seem overwhelming at times, but completing it thoroughly can be the difference between a paid or unpaid claim. The Triple Check Process also puts you more at ease for if/when an Additional Development Request (ADR) or insurance audit is requested.

To hear more from Richter Healthcare Consultants and learn how to best monitor compliance, review clinical documentation, and track claim issues, watch our on-demand webinar Audits, ADRs, and Documentation below: