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Inpatient Physician Accountability Reaches into the Part B Payment Pocket

Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, October 17, 2014 Posted in: Acute Care Rehab

Inpatient Denials May Also Rob Part B Payments

For some time now, I have heard that CMS may consider ways to deny part B payment when an inpatient stay has been denied. Depending on which side of the table you may sit, this is either good or bad news. It’s good news for acute care facilities that have physicians not particularly interested in playing the ‘payment game’ of documentation necessity but really bad news for those physicians not willing to jump through the hoops of documentation needed reality.

Either way, the buck stops here for part B payment when a ‘related’ claim can be used to validate and is associated with the patient being cared for.

The change request updates the CMS Manual 100-08 Medicare Program Integrity. Although it was published Aug. 8, the implementation came just one month later and can be enforced anytime by Medicare Contractors beginning September 8th. If you are looking at your calendar, that means it is in effect!

Are your physicians aware of this newest mandate and how this may affect their documentation standards? Are they truly in line with and aware of the intricasies that must be completed and at what time frames to enable a medically necessary admit? Whether an acute care stay or an inpatient rehabilitation stay, the consequences can be enormous; especially since CMS has just stated that a spot check on IRF documentation has resulted in a 90 percent failure rate for following ALL THE RULES.

CMS stated in the transmittal #534 the following, “The MAC performs post-payment review/recoupment of the admitting physician’s and/or surgeon’s Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provided as outpatient or observation), the MAC reviews the hospital record. If the physician service was reasonable and necessary, the service will be recoded to the appropriate outpatient evaluation and management service. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, postpayment recoupment will occur for the performing physician’s Part B service.”

It’s now more true than ever that the TEAM is responsible for the patient and the medical record expectations. Utilization Review and accurate documentation to support medical necessity has never been more meaningful as it relates to the physicians ability to be paid for their services. With the rate of denials, this is a sure-fire way for CMS to maintain more trust funds without sparing the medical care that was provided to heal the patient. It’s time to review your denial rates. Educate physicians to the newest change release and make them aware of the requirements to be paid for both inpatient and part B billing. Physician priviledge contracts should be updated so that language and expectations clearly note that related claims are equally susceptible to denial. Will CMS win the battle by attaching part B denials to inpatient care? Doing it in such a way means everyone will be on the same page when it comes to defending the care and oversight required to hospitalize an inpatient for the level of care. Time will tell – let’s see how serious the contractors will enforce this new transmittal.