Hospital providers understand that medical necessity documentation alone does not guarantee payment for the services they provide. Those who want to stay up to date on billing rules and code in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines to avoid denials rely on education from leaders in the field.
At Accretive Health, the physicians in the company's Accretive Physician Advisory Services (AccretivePAS®) division are known nationally for their expertise on this topic. In fact, two of these experts, Ronald Hirsch, M.D., vice president of the AccretivePAS® regulations and education group and Steven Meyerson, M.D., senior vice president of the AccretivePAS® regulations and education group, recently spoke to healthcare leaders from across the country who attended the 8th National RAC and MAC Summit in Washington, D.C.
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"We receive questions on a daily basis regarding billing issues, most recently due to confusion regarding the two-midnight rule," stated Dr. Hirsch, who conducted a networking lunch at the summit that focused on advanced beneficiary notice (ABN), hospital-issued notice of non-coverage (HINN), and Condition Code 44. "One provider asked if the Condition Code 44 still applies because she was seeing exceptions, such as doctors admitting patients as inpatients and then on the day of discharge changing the status to observation without consulting the UR committee. The answer is that there are no exceptions. A physician can never downgrade a Medicare patient from inpatient to outpatient without UR committee physician involvement."
"There continues to be confusion about rebilling," added Dr. Meyerson, who spoke at the same Washington summit about how to rebill Medicare Part B when a Part A payment is denied. "There's actually some good news to be shared about the CMS' ruling on rebilling Part B. Hospitals now have the opportunity to be paid for all medically necessary services when rebilling under Part B if a Part A claim is denied because the inpatient admission was deemed to have been 'not reasonable and necessary' by a Medicare auditor or through prebilling self-audit. And when denials are going to be appealed, it's a matter of knowing how to handle the appeals process, work with the auditors, and stay within the designated timelines. Unfortunately, CMS has reimposed the one year timely filing deadline, so if a Part A claim is denied more than one year after the date of service, it can't be rebilled. This has led hospitals to do more self-audits and self-denials to enable Part B rebilling within that deadline."
Attendees at conferences that have featured these Accretive Health spokespersons have commented on the effective, practical advice they offer, the clarity that they provide to a difficult subject matter, and how great is it to learn from physicians with such a thorough knowledge of utilization review.
At last month's National Association of Physician Advisors (NAPA) Inaugural West Coast Physician Advisor Summit in Anaheim, Calif., Dr. Hirsch clarified for nearly a hundred clinicians CMS' new use of "presumption" and "benchmark" for inpatient and observation care, provided tips on determining the best approaches for hospital review of cases, and reiterated how to best apply the rules regarding Condition Code 44 and Part B rebilling.
"It's all about compliance," he advised. "We help our clients explore strategies that will help them comply with the rules and receive appropriate reimbursement for their patient services."
For more information on working with the staff at Accretive Health's AccretivePAS® division, contact 312-324-7820, or visit www.accretivehealth.com.
AccretivePAS® is a comprehensive physician advisory medical necessity solution that helps hospitals and medical facilities confirm their navigation of the regulatory environment so that compliance improves.
About Accretive Health
At Accretive Health, our mission is to partner with healthcare communities to serve as a catalyst for a healthier future for all. For more information, visit www.accretivehealth.com.