The complexities surrounding Medicare regulations and billing procedures often lead hospitals to miss out on important revenue opportunities. Hospitals are often hesitant when misapplying guidance and standards set forth by the Centers for Medicare and Medicaid Services (CMS). It is imperative that all departments in a hospital are on the same page when it comes to these areas. In her recent article published in Health Leader Magazine, Kimberly A.H. Baker, JD, CPC, clarifies the common misconceptions of CMS standards that ultimately lead to revenue loss. With this, she offers three patient status rules to follow to ensure that your medical center will receive accurate and on-time payments.
Distinguish Overnight Stays from Observation for Part A Payment
CMS guidelines for admission are often misinterpreted as a rule stating that a patient must meet inpatient requirements under InterQual or MCG to be covered. Instead, it is crucial to consider that all medically necessary outpatient care should be considered with the accurate CMS metric of ‘two midnights’ in mind for admission as the basis for determining whether or not the stay fits with Part A payment. This specific metric provides a standard that distinguishes overnight hospital stays from those that are categorized by medical observation to determine whether or not Part A payment should be applied. Cases of medically necessary observation typically fit into the Part A payment and do not exceed 48-hour stays.
Consider Self Denials and Complexities of Part B Payments
For inpatient cases that do not necessarily fit within inpatient requirements, CMS allows for full inpatient Part B payment. However, with the consideration of self-denials in mind, it is also essential to consider the many complexities that could sway revenue, including denials and third-party insurance authorizations.
Pay Attention to Changes in Inpatient-Only Procedures
Because the list of inpatient-only procedures changes each year, it is important to pay attention to which procedures are newly added to the list. It is also important to consider that an inpatient order is necessary to receive payment. Without the order, it is nearly impossible to attain the accurate payment for the procedure. Employee training and emphasis on this point is crucial for ensuring that inpatient orders are not missed or misplaced.
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