Jeannine LeCompte, Publishing and Research Coordinator
The Medicare “Triple Check Process” is officially defined as a “systematic verification of the accuracy of data prior to submission of claims to the fiscal intermediary.” In practical terms, this means that the administration of a Medicare- or Medicaid-approved Skilled Nursing Facility (SNF) must ensure that all claims for reimbursement are accurate to the greatest possible extent before submission to CMS for payment.
This process must be in place to prevent the submission of false claims, to reduce the number of adjusted or denied claims, to ensure that residents receive the benefits to which they are entitled, and to ensure that all relevant clinical documentation is accurately recorded in the medical record and correlates with financial data.
Implementing the Triple Check Process requires input from the SNF’s Business Office, the Therapy Department, the Nursing Department, the Minimum Data Set (MDS) Coordinator, and the Clinical Manager.
The Business Office is responsible for the lion’s share of the Triple Check Process. It must undertake the following tasks:
- Verifying via the Common Working File that the resident has Medicare benefit days available
- All qualifying stays listed on the uniform billing form (UB-04) correspond with medical record dates
- The census log admit date agrees with all entries on the UB-04
- All residents’ names, social security numbers, and Medicare numbers are accurate and verified
- The Notice of Medicare Non-Coverage (NOMNC) letter submission is timely, and that vendors do not bill Medicare directly for items included in the facility’s required Medicare A consolidated billing, such as laboratory, radiology, pharmacy, and equipment
- The Medicare Secondary Payer (MSP) form is signed and dated, as appropriate
- No claims are submitted by working age Medicare beneficiaries who are covered by an Employer Group Health Plan or other insurance
The Therapy Department is responsible for the following:
- Verifying that all therapy minutes recorded in the daily treatment grid agree with the service log for all therapy disciplines
- Ensuring that all days and minutes recorded on the MDS correspond with the treatment grid
- Ensuring that principle and secondary diagnoses related to skilled care are listed accurately
- Ensuring that the number of units billed on the UB-04 correspond to the therapy service log
The Nursing Department is responsible for:
- Verifying that all documentation supports Medicare skilled interventions during dates of service which correspond with the census log
- Ensuring that the physician certification/recertification form is completed and signed by ordering physician
- Verifying that physician orders are received and implemented
- Ensuring that charting is completed at least once every 24 hours to support the skilled service being received, including charting that supports therapy services
The MDS coordinator is responsible for the following:
- Validation that the Patient Driven Payment Model (PDPM) level of each MDS agrees with the UB-04
- Verification that the MDS assessment type agrees with the UB-04
- Confirmation that the Activities of Daily Living (ADLs) are correctly entered and supported by documentation
- Ensure that Section GG Functional Abilities and Goals accurately depicts each resident’s performance
- Corroborating that all contributary items/interviews are coded
- Substantiating that all International Classification of Diseases, 10th edition (ICD-10) codes are correct and correspond to diagnoses
- Determining that every MDS used in the process corresponds to a validation report received from the MDS repository
The Clinical Manager is responsible for:
- Chairing the Medicare Triple Check meeting
- Ensuring that all participant responsibilities are completed prior to Medicare claims submission
- Monitoring the effectiveness of the interdisciplinary team interactions
Triple Check team members must come to the meeting prepared to discuss their portion of the process. Meeting time is not for completing their work, but for confirming that it is completed and that all items are correct All of the data sets must agree and tally with each another, and any claims in which errors are identified must be put on hold until the identified issue is corrected. The entire process needs to be finalized several days before billing is due to allow time to correct any issues which may arise.
