IPA denying inpatient claims

johncyrose

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Lodi, CA
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Just wanted to find out from others what their experience had been in this situation and what have been done to get these claims paid.

We have an IPA denying our claims stating that patients are only authorized for short stays. Pt has been admitted to inpatient after the admitting physician saw the patient for initial evaluation in the ER. The patient was in the hospital for 3 days. I understood that per Medicare guidelines, I am able to use 99234-99236 or 99218-99220 for stays less than 24 hours within the same calendar day. I understood that if it's more than that (up to 72 hours, rarely more), I can use the appropriate observation codes if during that period the patient remained in observation/outpatient status in the hospital. I am not sure what to do to get our inpatient claims paid given their short stay authorization but was admitted as inpatient. I code for the physician services.

I was wondering if the facility should have done something to update the IPA of the change in the patient's status as soon as it changed from obs/ER/outpatient to inpatient to get authorization for the inpatient stay, and there's nothing we can do if that didn't happen and the patient has already been discharged.

Appreciate your inputs.
 

RDK720

Networker
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Hi. It must be their coverage benefits, but you can just tell the IPA that this was an ER to IP Admit. Some IPA have a time frame that starts on the admit date to get an auth, but if its an emergency, they should cover the services unless they stated that the patient needed to be transferred to a different hospital and get admitted there. The Hospital may have an auth that you can use to bill for Pro Fee.
 

johncyrose

Contributor
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13
Location
Lodi, CA
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Hi. It must be their coverage benefits, but you can just tell the IPA that this was an ER to IP Admit. Some IPA have a time frame that starts on the admit date to get an auth, but if its an emergency, they should cover the services unless they stated that the patient needed to be transferred to a different hospital and get admitted there. The Hospital may have an auth that you can use to bill for Pro Fee.
Apparently, our denials team have tried appealing this before and had been unsuccessful. So now we are looking for other ways to help us have a work around this for the rendered services to be appropriately reimbursed.

Have you had any success in appealing these cases on your end? Did you use a specific wording in your appeal that maybe we can use, too?
 

RDK720

Networker
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48
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Apparently, our denials team have tried appealing this before and had been unsuccessful. So now we are looking for other ways to help us have a work around this for the rendered services to be appropriately reimbursed.

Have you had any success in appealing these cases on your end? Did you use a specific wording in your appeal that maybe we can use, too?
We had similar denials. On one where it was not authorized, we were successful in appealing whenever the encounter originated in the ER. We had to review the coverage and benefits of the IPA though and if it has Emergent/UR care services covered, we appeal. On the off chance that the IPA wont budge, we contact the patient to get them to call their IPA. Even if our appeals are exhausted, the patient's call allows us another round where they need to show who is the responsible party. The IPA will pay eventually, since they can't put in writing "patient responsibility" on ER encounters.
 

johncyrose

Contributor
Messages
13
Location
Lodi, CA
Best answers
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We had similar denials. On one where it was not authorized, we were successful in appealing whenever the encounter originated in the ER. We had to review the coverage and benefits of the IPA though and if it has Emergent/UR care services covered, we appeal. On the off chance that the IPA wont budge, we contact the patient to get them to call their IPA. Even if our appeals are exhausted, the patient's call allows us another round where they need to show who is the responsible party. The IPA will pay eventually, since they can't put in writing "patient responsibility" on ER encounters.
Thanks so much for taking the time to respond to my queries!
 
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