Corporate Compliance

CMS issues proposed changes to Part B inpatient billing in hospitals

Medicare Insider, March 19, 2013

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On March 13, CMS issued a notice of ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim that a Medicare review contractor deemed to be not reasonable or necessary. The revisions are intended as an interim measure until CMS can finalize an official policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward.

This temporary ruling is effective until CMS finalizes the accompanying proposed rule, which proposes a permanent policy that would apply on a prospective basis. Specifically, CMS is proposing the following:

When a Part A claim for inpatient hospital services is denied because the inpatient admission was deemed not to be reasonable or necessary, or when a hospital determines under § 482.30(d) or § 485.641 after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary, the hospital may be paid for all the Part B services (except for services that specifically require an outpatient status) that would have been reasonable and necessary had the beneficiary been treated as a hospital outpatient rather than admitted as an inpatient, if the beneficiary is enrolled in Medicare Part B.

While the CMS ruling acquiesces to the current ALJ and Appeals Council rulings to award Part B payment as timely if the original Part A claim was timely, the proposed rule would reverse this ruling and require inpatient Part B claims be filed within the one-year timely filing period. Providers should comment to CMS on the impact of this policy and the operational difficulty that it may present. In the meantime, they should take every opportunity to avail themselves of the CMS Ruling before it is superseded by a final rule that again requires inpatient Part B claims to be submitted within timely filing.

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