Reconciling Skilled Nursing Facility Drugs Payment

By March 12, 2021Audits, Part D, SNF

Recent 1/3 Financial Audits have focused on the accuracy of billing of medications while a member is in a skilled nursing facility (SNF).   Most drugs administered during an acute stay in a SNF are covered under the global pricer for acute SNF stays.  Certain high intensity chemotherapy drugs which are billed separately under Part B outside of the facility’s bundled Part A payment are an exception to the global pricer rule.   However, drugs administered to Medicare beneficiaries that are in a SNF as a Long-Term Care patient or as a Nursing Home patient are covered under Part D.  The 1/3 Financial Audits are reviewing medications paid under Part D to confirm the accuracy of the billing when there are medical claims denoting the member was in a SNF under an acute stay.  Plans should identify members with stays in a SNF to determine if their stays were acute and should have been billed under Part A.  Medical claims, TRR values, the LTI report and/or prescription drug claims should be used to identify claims inappropriately billed under Part D.  Prescription drug event (PDE) data for claims identified as billed under Part D for acute stays should be reversed.  Additionally, plan sponsors should outreach to the SNF facility to adjust the billing accordingly.