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SNFCB History

SNFCB = Skilled Nursing Facility Consolidated Billing is a division of Consolidated Billing Services Inc. CBSI was founded by Bill J. Ulrich in April of 1998 specifically to meet the increasing clinical and financial challenges of tomorrow. Mr. Ulrich authored a PPS / Medicare manual for Skilled Nursing Facilities (SNF), writes a monthly Billing Advisor article for Provider magazine and has contracted to develop a model reimbursement system for the Washington Health Care Association. CBSI currently offers compliance programs to more than 25 long term care facilities and files over 200 federal and state cost reports a year.

Medicare Billing Simplified

In 1997 the federal government made sweeping changes regarding Medicare Billing. These changes created new challenges for many Skilled Nursing Facilities and other Medicare providers. Proper Medicare billing became even more complicated as government amendments and modifications were implemented. Hearing from his clients that there was a need to simplify the process, Bill took matters into his own hands.

In September of 2005 Bill launched the first version of Medicare billing professionals could now get all their questions answered at one easy-to-use website. Over the years the site has added multiple features and enhancements to make it an even more valuable asset to its members.

Today, has analyzed thousands of Medicare Claims worth millions of dollars. The fact that 96% of our customers renew their membership speaks volumes. Skilled Nursing Facilities and other Medicare providers, save time and money by using

Medicare Consolidated Billing in a nutshell.

The Balanced Budget Act of 1997 requires that all Medicare covered services provided to an inpatient of Skilled Nursing Facility (SNF) be bundled to the SNF unless they have specifically been excluded. Essentially, this means that the SNF, along with each entity that provides services for SNF Part A inpatients must know what services are bundled to the SNF and under what circumstances each service is bundled. SNFs can no longer "unbundle" services that are subject to CB to an outside supplier that can then submit a separate bill directly to the Part B carrier. Instead, the SNF itself must furnish the services, either directly, or under an "arrangement" with an outside supplier in which the SNF itself (rather than the supplier) bills Medicare. The outside supplier must look to the SNF (rather than to Medicare Part B) for payment.

The Medicare program provides for payment to the SNF under one of sixty six Resource Utilization Groups (RUGS) for the entire bundle of services. It is the responsibility of the SNF to make arrangements for all services its patients may require. A critical part of the arrangement is the determination of the amount charged by the supplier and paid by the SNF. It is important to note that neither the Center for Medicare and Medicaid Services (CMS) nor the Office of the Inspector General (OIG) require any specific level of payment. The SNF and the supplier are free to negotiate price. In almost every case, the applicable fee schedule is the baseline for calculating payment. Our web page at specializes in knowing what services are bundled, why they are bundled and provides the applicable Medicare fee schedule.

Significant Events

Prior to July 1, 1998

Prior to the Balanced Budget Act of 1997 (BBA), a SNF could elect to furnish services to a resident in a covered Part A stay, either Directly, using its own resources; Through the SNF's transfer agreement hospital; or Under arrangements with an independent therapist (for physical, occupational, and speech therapy services). In each of these circumstances, the SNF billed Medicare Part A for the services.

However, the SNF also had the further option of "unbundling" a service altogether; that is, the SNF could permit an outside supplier to furnish the service directly to the resident, and the outside supplier would submit a bill to Medicare Part B, without any involvement of the SNF itself. This practice created several problems, including a potential for duplicate (Parts A/B) billing; an increased out-of-pocket liability incurred by the beneficiary; and a dispersal of responsibility for resident care among various outside suppliers adversely affected quality.

Balance Budget Act of 1997 [Effective July 1, 1998]

Congress then enacted the Balanced Budget Act of 1997 (BBA), Public Law 105-33, Section 4432(b), and it contains a Consolidated Billing (CB) requirement for SNFs. Under the CB requirement, an SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services). Conceptually, SNF CB resembles the bundling requirement for inpatient hospital services that's been in effect since the early 1980s—assigning to the facility itself the Medicare billing responsibility for virtually the entire package of services that a facility resident receives, except for certain services that are specifically excluded. CB eliminates the potential for duplicative billings for the same service to the Part A fiscal intermediary by the SNF and the Part B carrier by an outside supplier. It also enhances the SNF's capacity to meet its existing responsibility to oversee and coordinate the total package of care that each of its residents receives.

CMS Program Memorandum A-98-37

In Program Memorandum (PM) Transmittal # A 98 37 (November 1998, reissued as PM transmittal # A-00-01, January 2000), CMS identified specific types of outpatient hospital services that are so exceptionally intensive, costly, or emergent that they fall well outside the typical scope of SNF care plans. CMS has excluded these services from SNF CB as well (along with those medically necessary ambulance services that are furnished in conjunction with them). These excluded service categories include:

  • Cardiac catheterization;
  • Computerized axial tomography (CT) scans;
  • Magnetic resonance imaging (MRIs);
  • Ambulatory surgery that involves the use of an operating room;
  • Emergency services;
  • Radiation therapy services;
  • Angiography; and
  • Certain lymphatic and venous procedures

Balanced Budget Refinement Act of 1999 (BBRA) [Effective April 1, 2000]

Effective with services furnished on or after April 1, 2000, the Balanced Budget Refinement Act of 1999 (BBRA, P.L. 106-113, Appendix F) has identified certain additional exclusions from CB. The additional exclusions enacted in the BBRA apply only to certain specified, individual services within a number of broader service categories that otherwise remain subject to CB. Within the affected service categories the exclusion applies only to those individual services that are specifically identified by HCPCS code in the legislation itself, while all other services within those categories remain subject to CB. These service categories include:

  • Chemotherapy items and their administration;
  • Radioisotope services; and
  • Customized prosthetic devices.
  • In addition, effective April 1, 2000, this section of the BBRA has unbundled those ambulance services that are necessary to transport an SNF resident offsite to receive Part B dialysis services.

Benefits Improvement and Protection Act of 2000

The original CB legislation in the BBA applied this provision for services furnished to every resident of an SNF, regardless of whether Part A covered the resident's stay. However, due to systems modification delays that arose in connection with achieving Year 2000 (Y2K) compliance, the Centers for Medicare & Medicaid Services (CMS) initially postponed implementing the Part B aspect of CB, i.e., its application to services furnished during non-covered SNF stays. This aspect of CB has now essentially been repealed altogether by Section 313 of the Benefits Improvement and Protection Act of 2000 (BIPA, P.L. 106-554, Appendix F). Thus, with the exception of physical, occupational, and speech-language therapy (which remain subject to CB regardless of whether the resident who receives them is in a covered Part A stay), this provision now applies only to those services that an SNF resident receives during the course of a covered Part A stay.

CMS Final Rule [Effective January 1, 2004]

Finally, effective January 1, 2004, as provided in the August 4, 2003 final rule (68 Federal Register 46060), two radiopharmaceuticals, Zevalin and Bexxar, were added to the list of chemotherapy drugs that are excluded from CB (and, thus, are separately billable to Part B when furnished to a SNF resident during a covered Part A stay).