Hospitals Struggle With Medicare Billing

The Centers for Medicare and Medicaid (CMS) Administrator Marilyn Tavenner announced a new Medicare ruling as response to wrong care setting disputes.  A patient is admitted to a hospital per medical doctor assessment.  During the inpatient stay hospital (UR) utilization review determines the treatment is appropriate and should be billed inpatient.  The patient is released and goes home with supportive care (www.homecarepath.com ) to recover.

After the hospital stay has been documented, billed, and reimbursed Medicare will conduct an audit.  Recovery Audit Contractors (RAC's) are private hires who perform the reviews that can result in a denial of payment.  So, the money Medicare reimbursed the hospital for the inpatient treatment delivered under Medicare Part A, must be sent back to the Centers for Medicare and Medicaid.  CMS was refusing to pay hospitals for services being identified on audit as covered under Medicare Part B.

In November 2012 The (AHA) American Hospital Association and 3 Medical Centers filed litigation against (HHS) Health and Human Services over a mandate that denies Medicare payment to hospitals when utilization review retroactively (post treatment delivery) determines the care could have been provided in an outpatient setting. 

This new rule authorizes acting judges of Medicare wrong care setting cases to allow hospitals to claim Part B inpatient costs in presented hospitalizations  where the setting of care has been deemed incorrect.  This includes separate billing of  Medicare Part B outpatient services that may have been bundled in to Part A with the first claim process.

The two variables associated with the new Medicare ruling involve time limits and process adjustments.  Typically submission for a Medicare Part B claim cannot exceed the 12 months post service.   How will the process that returns privately paid percentages collected at the higher inpatient service rates to individuals served by the hospital look.  The consumers cost share should drop dramatically with the lower level of care resulting in many patients receiving money as a refund.

Home Care Path encourages viewers to watch this health care issue closely as it unfolds.  Wisconsin's PATH ALONG model helps seniors during the hospital stay and with outpatient treatment visits.  PATH ALONG is a strong arm of Home Care Path www.homecarepath.com a community based organization  committed to performing a service that supports the changing needs of an aging population.  You are cordially invited to down load your free PATH ALONG App today

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