Often I am asked if there is a place people can reference to find the issues that are most often cited as Medicare billing errors. What problems most often cause an increased error rate? I stumbled across a great publication which I think you should be aware. The publication is called Newsletter Link – Medicare Qtrly Compliance Newsletter” Quarterly Compliance Newsletter and is made available at the Medicare Learning Network site.
In gleaning through this particular issue I find two items I have heard discussed and I have been questioned about: 1. transfer payments when a patient is discharged from your care to another provider that accepts Medicare part A payment, and 2. expect bundled charges when a patient receives diagnostics or services just prior to an inpatient Part A stay, even if you thought you provided those services as an ‘outpatient.’
On page 10 of the newsletter, it states that acute care facilities often incur underpayments related to transfer information on their bill. Recall that if a patient leaves an IPPS paid bed and then is discharged to another provider that accepts part A reimbursement, this can result in a transfer payment rule which is a perdiem rate if they do not stay for the full projected DRG length of stay. Why does the underpayment occur? Because Medicare contractors expect to see a claim from a ‘receiving facility.’ If a receiving facility does not submit a claim, yet the acute care bill has stated that the patient has been discharged expecting part A services to continue, then your bill was handled as though it should have been paid at the transfer rule rate. This is great news for providers. Expect money back, you were ‘shortchanged’ by accident!
I can imagine that one of those scenarios that could most often happen is that a patient expects to receive home health within three days of discharge (06 transfer code), however once they are settled, decide they can receive services as an outpatient or for some other reason the service is not provided within the intended time frame. With an increased workflow to improve post discharge follow-up to reduce readmission within 30 days, be sure to ask the patient if their intended discharge location and services were fulfilled. You may be able to submit a correction for full payment if you catch this unexpected change.
The other area of interest and most often discussed with me is services provided just prior to an inpatient stay (planned or unplanned). If diagnostics were provided within three days of the hospitalization (using the midnight rule), expect that those services will be part of the IPPS payment. Again, if other services were provided within one day of admission, such as therapy in preparation for surgery etc., when provided by the hospital or an entity under arrangement with the hospital the day BEFORE the IPPS Part A paid inpatient stay, then those too will not be paid as an outpatient service but will be pulled into the Part A DRG payment.
For our respiratory clients, you will find a discussion on nebulizer overutilization on page 8, and pulmonary procedure problem billing on page 25 equally as interesting in the prevention of errors on the uniform bill.
Often ‘errors’ occur because intended circumstances in reality just don’t happen. I am certain you can review other resources provided by MLN along with your own book of business and create highlights and stopgaps from keeping those items you deal with most often out of your error rate!