Resident Billed in Error for Covered Services After Successful Appeal
Penalty
Summary
The facility failed to ensure accurate billing practices by charging a resident's account for services that were covered by insurance after the resident successfully appealed a Notice of Medicare Non-Coverage (NOMNC). The resident was admitted under skilled nursing care following hospitalization and received a NOMNC, which was subsequently appealed. The appeal was successful, with the Quality Improvement Organization (QIO) determining that ending services was not appropriate due to the facility's failure to provide required documentation in a timely manner. Despite this, the facility transitioned the resident to Private Pay/Medicaid Pending status and began billing at a private pay rate, resulting in a significant outstanding balance. The error occurred because the facility did not properly communicate the appeal outcome or update the payer source accordingly. Staff failed to read and act on the QIO documentation, and the change in payer status was not relayed to the corporate Care Management Team. As a result, the resident was incorrectly billed for services that should have remained covered by insurance, leading to confusion and distress for the resident's representative, who was informed of a large outstanding balance and the need to remove the resident from the facility. The deficiency was attributed to corporate oversight and lack of communication between facility and corporate staff.