CMS Edit Preventing Reimbursement to RHCs for SNF Services

Nathan Baugh, Executive Director, NARHC

A billing issue introduced by a July 1st CMS quarterly edit to the Fiscal Intermediary Shared System (FISS), has caused widespread denials, rejections, and recoupments of RHC Skilled Nursing Facility (SNF) claims.

Impacting CPT codes 99304 through 99309, NARHC estimates that this edit is thwarting the proper adjudication of over 92,000 RHC claims per month. In terms of financial impact, our calculations are that this edit has caused approximately $20 million of Medicare reimbursement per month to be erroneously withheld from Rural Health Clinics.

Through our discussion forum, NARHC was able to gather evidence of the issue and bring it to the attention of CMS in early September. After a period of time, CMS asked NARHC for additional evidence of this issue, and we promptly provided more claims denial and recoupment examples. While CMS staff has indicated to us that they are researching the problem, as of the time of writing, the only public acknowledgement we have from either CMS or the MACs of this issue is an alert from WPS that they reported it to the FISS for investigation.

NARHC is committed to getting this issue resolved as fast as possible. Updates will be shared on our discussion forum as soon as we have them, and we will send out an email on our listserv once a definitive resolution has been identified.

Given the substantial volume of claims impacted, resolving this issue is a top priority for NARHC and we will work diligently to elevate the issue to CMS leadership and other policymakers as appropriate.