Wiki MA plans and alt level of care

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mfn1974

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Running into semantics with the UM team related to alt level of care with MA plans.... I'm interested to know how others finalize a bill that has been denied due to nonqualification for an inpatient stay, particularly when the denial states the carrier considers it to be Obs. Do you rebill Obs (although the order states inpatient) using the letter as your "justification" or do you follow Medicare guidelines?
 
Hi MFN
Did the provider state in his or her documentation it was observation or pt required inpatient stay? Also was it verified during preapproval call with the payer the patient was inpt. NOT observation for certain diagnostic problem? Also cannot bill of OBS when it was inpatient. I d rebill if it time has not run out to fix the denial. However most payers when you calling for preapproval must give dx correct and type of visit want approved. If that was not done correctly....lost funds.
Lady T
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Are you talking about your internal UM team? Was the stay changed after the initial claim(s) went out? There should be an internal policy and procedure on this within the organization. There are numerous instances where the provider might write an inpatient order but the stay ends up being changed to observation. Did the claim(s) go out so fast that there was not time to double check the patient disposition in the final chart?
I have personally seen where practices bill inpatient only to find out later the internal UM team and chart was updated to observation. In those cases, corrected claims were required.
 
amyjph said:
Are you talking about your internal UM team? Was the stay changed after the initial claim(s) went out? There should be an internal policy and procedure on this within the organization. There are numerous instances where the provider might write an inpatient order but the stay ends up being changed to observation. Did the claim(s) go out so fast that there was not time to double check the patient disposition in the final chart?
I have personally seen where practices bill inpatient only to find out later the internal UM team and chart was updated to observation. In those cases, corrected claims were required.
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The order is for an inpatient stay, however the MA plan denies and states it qualifies for Obs... the letter doesn't state to rebill it that way, however the UM team is thinking that is enough justification to do so. In following Medicare guidelines, this practice is not acceptable (order is "inpatient" but we are billing Obs just to get paid). As MA plans are structured to follow Medicare guidelines, there is a bit of a grey area we are trying to sort out. Would you stick with Medicare guidelines and avoid the grey altogether?
 
There should be an internal policy and procedure on this within the organization. There are probably state/facility and other clinical rules around this too. It would be either a change of status as determined by the facility UM nurse or other provider or appeal to be covered as inpatient I think. I don't think it's a matter of just rebilling it because the payer doesn't want to cover it, it requires review.
And yes, MA plans generally follow Medicare, but if the plan has a specific guideline or rule for coverage or according to your contract, you would have to follow that.

Not "official" but info: https://racmonitor.medlearn.com/rebilling-non-medicare-inpatient-claims-is-it-observation-or-not/
 
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