Mental Health Billing for Nursing-Home and Assisted-Living Providers

Many behavioral-health providers who do this work round in more than one kind of setting. A Tuesday might include a skilled nursing facility, a long-term nursing facility, and an assisted-living community. The clinical work may feel similar from one building to the next. The billing is not. A skilled nursing facility, a nursing facility providing non-skilled or custodial care, and an assisted-living community are distinct settings with distinct billing treatment, and an assisted-living community is not a nursing home for billing purposes even when the buildings sit on the same campus.

Treating these settings as interchangeable is one of the most common reasons facility-based behavioral-health claims are denied or misrouted. We start every claim by confirming where the patient actually was on the date of service and what that setting means for how the claim must be built.

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Two residents in the same building, seen on the same day for the same service, can require different claim handling. What matters is each resident’s status and coverage on the date of service: whether the resident is in a Medicare Part A skilled stay, receiving non-skilled nursing-facility care, or living in an assisted-living setting where the visit is billed more like a residence visit.

Medicare skilled stays add a layer that office billing never encounters. During a Part A skilled stay, Medicare’s consolidated-billing rules make the facility responsible for billing certain services, while other professional services are billed separately by the provider. Whether a particular behavioral-health service is billed separately or falls under consolidated billing depends on the specific service, the provider type, the resident’s coverage and status, and the Medicare or payer requirements that apply. There is no single answer that covers every visit, which is exactly why the determination has to be made claim by claim rather than assumed.

That determination is our job, not yours. We identify how the professional claim should be handled for that resident on that date, submit it accordingly, and follow it through payment.

We set the billing up correctly from the first claim, so you never accumulate the backlog that many practices spend years digging out of.

For Medicare, place-of-service code 31 generally applies when the patient is in a covered Part A skilled nursing facility stay. Code 32 applies to nursing-facility residents, including SNF residents who are not in a covered Part A stay. Code 13 applies to assisted living. In other words, the code turns on the patient’s coverage status on the date of service, not just the building, and the same patient in the same bed can require a different code once the Part A stay ends. These codes carry different payment treatment, and a claim submitted with the wrong one can be denied, underpaid, or flagged. We confirm the patient’s setting and covered status for the date of service instead of carrying a code forward from the last visit.

The setting and the resident’s status affect not just the code on the claim but where the claim goes. A service that belongs with the Medicare Part B professional claim, a service that falls under the facility’s consolidated billing during a skilled stay, and a service routed through a Medicare Advantage or behavioral-health payer arrangement do not all travel the same path. Sending a claim down the wrong path produces denials that look mysterious on a remittance but are entirely preventable. We confirm payer responsibility and routing before submission rather than sorting it out afterward.

Facility-based denials rarely happen once. If a claim is denied because the place-of-service code did not match the resident’s setting, or because a service was submitted to the wrong payer during a skilled stay, the same condition usually exists on other visits: the same resident’s next appointment, other residents in the same facility, or every claim touched by the same payer rule.

When we work a denial, we identify the reason behind it, then check whether that reason is affecting similar visits, residents, facilities, or payers before it produces the next round of denials. A fixable pattern gets corrected once instead of denied on repeat, and you hear about what we found and what changed rather than watching the same denial code reappear month after month.

Billshrinkers handles the professional billing for the behavioral-health provider: your claims, for your services, to the residents you see. We do not bill room and board, facility charges, institutional claims, or any part of the nursing home’s or assisted-living community’s own operations. The facility is where your patient lives; you are our client.

Credentialing, meaning enrollment with insurance panels, is a separate specialty that we refer to an outside credentialing specialist rather than handling in-house. Once you are enrolled with your payers, your billing runs through us.

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Yes. We bill this work today for providers who see patients in skilled nursing, nursing-facility, and assisted-living settings. We handle the professional claim for the provider; we do not bill the facility’s own charges.

They are distinct settings with distinct claim treatment. For Medicare, place-of-service code 31 generally applies when the resident is in a covered Part A skilled nursing facility stay, code 32 applies to nursing-facility residents and SNF residents who are not in a covered Part A stay, and code 13 applies to assisted living. The setting and the resident’s coverage status can also affect which payer is responsible for the claim and which billing rules apply, so we confirm both for every date of service.

During a Part A skilled stay, Medicare’s consolidated-billing rules make the facility responsible for billing certain services, while other professional services are billed separately by the provider. Whether a specific behavioral-health service is billed separately depends on the service, the provider type, the resident’s coverage and status, and the applicable Medicare or payer requirements. We make that determination for each claim rather than assuming one rule covers every visit.

Yes. Behavioral health is the only field we work in, and facility-based providers across these credentials are part of who we bill for. Payer rules can differ by provider type, and we account for those differences in how each claim is prepared and submitted.

Credentialing is handled by an outside specialist we refer you to, so our full focus stays on the billing. Once you’re enrolled with your payers, we take it from there.

Bring us the specifics: which skilled nursing, nursing-facility, or assisted-living settings you round in, the payers involved, how you currently find out a resident’s status on the date of service, and where your denials or follow-up problems are showing up now. We will tell you plainly how we would handle the setting determinations, place-of-service coding, claim routing, and follow-up your claims need.

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