Health Information Management

News: CMS releases new guidance for rebilling necessity denials

CDI Strategies, March 28, 2013

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It was hardly explicit that organizations could rebill on an outpatient basis (or fully bill) for services denied as non-medically necessary in an inpatient setting. However, on March 13, CMS issued a notice of ruling which may provide some financial relief for facilities receiving Part A stay denials, according to Valerie A. Rinkle, MPA, vice president of Revenue Integrity Informatics with HRAA, headquartered in Plantation, Fla.

Specifically, CMS proposes that facilities can receive payment for the outpatient services it renders when a claim is deemed not reasonable for inpatient services. The ruling states:
“When a Part A claim for inpatient hospital services is denied because the inpatient admission was deemed not to be reasonable or 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.”
“We view this proposed rule as a positive development and will continue to work with CMS to ensure that hospitals are fully reimbursed for the care they provide to our nation’s seniors,” said AHA President and CEO Rich Umbdenstock, in an AHA News Now article. Last year AHA filed suit against the government on the rebilling issue.
The revisions are intended as an interim measure until CMS can finalize an official policy to address the issue. The temporary ruling is effective until CMS finalizes an accompanying proposed rule, which offers a permanent policy that would apply on a prospective basis. 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 additional measures related to timely filing ultimately undermine the decision, says Kimberly Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., of Danvers, Mass.
"If they don't fix the timely filing issues, they are simply moving the problem …," she says. "If this [proposed rule] goes though, providers won't be able to just wait for post-payment denials and rebill as they would under the ruling; they will have to be on top of their utilization review (UR) processes to take advantage of [the rebilling opportunity]."
Editor’s Note: This brief first published in the e-newsletter Medicare Insider. View the notice of ruling.
View the proposed rule. And k
eep an eye on to submit comments.


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