Draw Upon PART A Reserve Days for Inpatient Billing
By Jules Enatsky, RT, BSN, CPC-H
Institutions often are subject to patient encounters requiring extended care. Patients who contract drug resistant infectious diseases, for example, may require longer inpatient stays than the standard 90 days of consecutive inpatient acute care for which all Medicare beneficiaries are eligible under Medicare Part A.
Each beneficiary has an additional lifetime reserve of 60 days of inpatient hospital services to draw upon after exhausting the prerequisite 90 days of inpatient hospital services in a benefit period. Medicare policy dictates, “Payment will be made for such additional days of hospital care after the 90 days of benefits have been exhausted unless the individual elects not to have such payment made (and thus saves the reserve days for a later time).” This applies to emergency services as well, even at non-participating hospitals.
Details regarding lifetime reserve day availability and limitations are outlined in the Centers for Medicare & Medicaid Services (CMS) Medicare Benefits Policy Manual, chapter 5 (www.cms.gov/manuals/Downloads/bp102c05.pdf). The policy manual specifies that physician certification requirements are applicable to lifetime reserve days, and rules vary for inpatient psychiatric stays (which have a 150-day hospital reduction provision). These and additional provisions are not easily summarized, and should be read in their entirety.
Patients May Elect Not to Use Lifetime Reserve Days
A patient may elect in writing not to use lifetime reserve days within 90 days following a hospital discharge. More time is given if another payer source agrees to pay for services not payable under Part B, and the hospital agrees to accept the retroactive election. Note, however, that beneficiaries are considered to have not elected the lifetime reserve days if the average daily charge for covered services furnished during a lifetime reserve days billing period is equal to or less than the coinsurance amount for the lifetime reserve days.
Action Point: Hospitals are responsible for informing patients of their rights. The Medicare Benefits Policy Manual instructs:
“Hospitals are required to notify patients who have already used or will use 90 days of benefits in a benefit period that they can elect not to use their reserve days for all or part of a stay. The hospital notice should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized beyond that period. Where the hospital discovers the patient has fewer than five regular coinsurance days left, it should immediately notify the patient of this option. The hospital should annotate its records at the time that it informed the patient of this option. In addition, it should make available an appropriate election statement or form to be included in the patient’s hospital record if the patient elects not to use reserve days.”
If a beneficiary elects not to use lifetime reserve days, hospitals must bill covered ancillary services to the Part B program only if the patient is enrolled in that program. If election is not requested in writing, the lifetime reserve days would then be considered non-covered days and the beneficiary would be responsible for all charges. CMS provides model “election format” language to inform the patient of this responsibility, as follows:
Note: A beneficiary’s election not to use reserve days should specify the name of the hospital and the starting date of the election.
Patients May Revoke Lifetime Reserve Days
The patient also has the option to revoke his or her election not to use reserve days within a specified time, as outlined in the Medicare Benefits Policy Manual: “An election not to use reserve days may be revoked in whole or in part, provided a claim has not been filed for Part B ancillary services furnished on the hospital days in question … A revocation of election not to use lifetime reserve days must be made within 90 days following the beneficiary’s discharge from the hospital with the following exception: The election may be revoked later than 90 days after discharge if benefits are available from a private insurer to pay the lifetime reserve coinsurance amounts and the insurer requires as a condition for payment that lifetime reserve days be used.” The revocation must be submitted to the hospital in writing and should be made part of the patient’s hospital record.
Because of the number and types of exceptions that apply (including different rules for those hospitals paid under the physician fee schedule, and those that are not), I advise interested readers to further review chapter 5 of the Medicare Benefits Policy Manual. The manual provides examples to help illustrate the limitations and applicability of lifetime reserve days, and provides complete model “election format” language.
Jules Enatsky, RT, BSN, CPC-H, is senior consultant with JA Thomas & Associates. He has over 30 years of combined radiology technology, acute care nursing experience, and consulting for Part B hospitals and physicians.
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