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Payment Matters
September 27, 2007
To Err is Human. But It Won't Get Paid: Denial of Medicare Payment for Hospital-acquired Conditions
By: Emily H. Wein
Effective October 1, 2008, Medicare will no longer reimburse hospitals for the treatment of conditions that could have "reasonably been prevented." In addition, hospitals cannot bill beneficiaries for any charges associated with the hospital-acquired conditions. Hospitals need to get ready to submit secondary diagnoses information that is present at admission when reporting payment information for discharges. CMS recommends submitting such "present on admission" or "POA" codes by October 1, 2007, but for those submitting via direct data entry, such codes are mandatory beginning January 1, 2008.
The "preventable" conditions include, thus far, the following: falls; mediastinitis, an infection that can develop after heart surgery; urinary tract infections resulting from improper use of catheters; pressure ulcers; vascular infections resulting from improper use of catheters; and the following three "never events": objects left in the body during surgery; air embolisms; and blood incompatibility. Next year CMS plans to add three additional conditions to this existing list of eight. These conditions may include those that were proposed for inclusion in this final rule; however, CMS determined further investigation and information was needed before including them in this new policy. Some possibilities include: deep vein thrombosis (DVT)/pulmonary embolism (PE), staph infections/sepsis, pneumonia related to the use of a ventilator, clostridium difficile-associated disease (CDAD), Methicillin-Resistant Staphylococcus Aureus (MRSA), and wrong surgeries.
Click to continue...Physician-owned Hospitals Required to Provide Notice to Patients
By: Julie E. Kass
As of October 1, 2007, all hospitals that have physician ownership are required to furnish written notice to their patients at the beginning of a hospital stay or outpatient visit. The notice must disclose the fact that the hospital meets the definition of a "physician-owned hospital." In addition, the hospital must provide a list of the hospital's physician owners upon request. The notice must be provided to the patients at the first contact between the hospital and the patient. CMS believes this is usually when the hospital sends a package of information regarding scheduling, pre-admission testing and registration for a planned hospital admission or outpatient service.
These rules do not apply simply to specialty hospitals. Rather, a "physician-owned hospital" is defined as any participating hospital in which a physician or physicians have an ownership or investment interest. This ownership interest may be held directly or indirectly, and may be through any means, including equity or debt. The only exception for physician ownership is ownership in publicly traded securities or mutual funds. Hospitals not providing these disclosures may have their Provider Agreement terminated. Lack of disclosure procedures is also a basis to deny a Provider Agreement.
Click to continue...CMS Clarifies SNF Billing Requirements for Beneficiaries Enrolled in Medicare Advantage ("MA") Plans
By: Kristin Cilento Carter and John F. Lessner
On July 13, 2007, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal Number 1290, to remind operators of skilled nursing facilities and swing bed providers (collectively here, SNFs) that they must submit informational claims for beneficiaries in a Part A stay and enrolled in Medicare Advantage (MA) Plans to their fiscal intermediary (FI) or Part A/Part B Medicare Administrative Contractor (Contractor) for purposes of updating the beneficiary's Common Working File (CWF). However, the transmittal further clarifies that SNFs that provide services to beneficiaries enrolled in a MA Plan must look to the MA Plan for payment, rather than traditional "fee-for-service" Medicare.
Transmittal Number 1290 incorporates new provisions into Chapter 6 (SNF Inpatient Part A Billing) of the Medicare Claims Processing Manual that require SNFs to apply certain policies when providing services to MA Plan beneficiaries. Where a SNF does not participate in a beneficiary's MA plan, CMS clarifies that the SNF must notify the beneficiary that it does not participate in the MA Plan because the beneficiary would become private-pay under such circumstances. On the other hand, where a SNF participates in a beneficiary's MA plan, the SNF should seek pre-approval from the MA Plan for the SNF stay and if the plan denies coverage, the SNF must appeal such denial to the MA plan, rather than the Medicare FI or Contractor.
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