Hospital billing, part 1

Hospital billing, part 1

Steven L. Fries, L.C.P.O.

Thanks to all who responded to the hospital billing question. Below are some
of the replies I have received.

Steven,
Man, what a can of worms!  I had heard that some companies were providing
services to patients while in the hospital and billing with D.O.S. after the
fact,  but to know that hospitals are going along with it also is just
incredible.  I personally feel that providing a product or service on a
particular day must be noted in a patient's hospital chart, a legal set of
documents.  These documents, if subpoenaed in the future, could cost all
parties involved their contracts with the provider of coverage.  Seems like a
HUGE gamble for a $500 AFO.
Please post at least a summary of your responses.
Stoney Sherrill C.O.,L.

YOu are embarking on situations that I have been encountering for over three
years now in Houston.  I have turned the hospitals requests around and found
a way to make it profitable for me.  The way they have proposed doing
business is indeed risky.  What will they do for a trauma patient that will
be admitted for several days.  Another consideration is that if you bill the
insurance company directly, do you go into the patients room 2 days before
discharge and ask for a co-pay or a deductable?  Please feel free to call me
for details.
Joe Sansone

Hi Steve,
  It sounds like the hospitals are using the Two Day Rule. I believe a copy
of the policy would give you enough documentation to approach Medicare. It
would be to your advantage to get other O/P providers to join the band wagon.
I would try to find a physican advocate that my be on the hosp. board to have
these policy changed. You are right that o/p is included in the DRG.
Good luck
Steve Mersch CPO

Dear Steven,
I have the same concerns as you.  In our area we have the same problem with a
couple of hospitals but not all.  A local firm has been fitting the patient
in the hospital and billing on date of discharge.  In some cases there are
restrictions on how soon Medicare can be billed after discharge.
Please let me know your results.
Don Dixon, CPO

Yes I do have some experience with our local hospitals.  We do not get p.o.'s
for anything except m-care.  All other ins. m-caid or unfunded is at our own
risk.  When it comes to an unfunded patient, maintaining our relationship
with the referral source usually motivates us to take care of them.  That's a
little hard to stomach when we know we are getting squezed by the hospital.
Tom Martin

#1. Yes, these items are covered under DRG's, but can be billed to Medicare
as they suggest. 2 days prior to or on the day of discharge.
#2. Yes they are attempting to deflect payment responsibilities. O and P is
the first service cut in most hospitals.
#3. They are permissible, but this is a very touchy area. This is not to be
used as a substitute for hospitals to side step DRG payments, and
increasing their profits by doing so.
#4 Weekend consults are a problem. Have you ever tried to contact an auto
insurance company on a weekend to verify benefits as a result of an auto
accident.....or workers comp......or private insurance...etc.................
#5 Critical care.......indigent patients?  If they have no insurance, you're
stuck.
#6 General Medicare guidelines
  A.  If an orthosis is used initially in hospital, item should not be
delivered to patient before hospital admission. Items delivered to the home
before patient has need of them are denied by DMERC. But the provider can go
ahead and make it, fit it, but not bill Medicare, but bill the hospital.
  B. If item is dispensed and to be initially used in the hospital following
surgery for example, reimbursement is included in the DMERC DRG payment to
hospital. Hospital must pay for brace and all services.
  C. If item is intended for initial use after hospitalization and the item
is delivered to a hospitalized patient for the sole purpose of fitting or
training up to two days before discharge to the home setting, the item can be
billed to DMC with the discharge date as the date of service.
7. Many heated arguments with hospitals over this issue. They will do
anything to avoid paying for o and p services. Because of the problems you
mentioned, (i.e. weekend calls, no insurance etc...) and getting stuck with
many services not paid, we required the hospital to pay for all outside
services. This also can be to their benefit. They would usually mark up O &P
services 3x and bill the private or workers comp. insurance.
#8 Most of the physician's had no control. Case management places much
pressure on them to avoid unnecessary ordering of O&P services. Unless you
have a referral physician very influential in the hospital, (large source of
hospital revenue), profits become bottom line and they go with the flow.
In a nutshell, hospitals are trying to cut costs, and O&P is usually first to
go. Before this recent Medicare ruling, I have in years past been requested
by hospitals to change dates of service to bill Medicare. When explained this
was illegal and would not be considered, their reply was, We will find
someone who will! They usually find some local DME company that will do
it....especially for orthotics. Many physicians are discharging patients and
instructing them to obtain their O&P services on their own. 
Unless they are Medicare patients where you are assured payment will
eventually be received, be prepared to eat a lot of bills. Good luck
getting paid from a patient with no insurance, questionable benefits,
insurance lawsuits, workers comp cases in review.....etc...after you have
provided service.  Trying to get paid for our services under  normal
circumstances is difficult. This makes it impossible! Consequently, I do not
see many patients in the hospitals anymore!
Hope this helps
Mark

Steve:
  Under certain circumstances Medicare will allow billing for O&P items during
the last two days of a patient's in-hospital stay or Part A SNF stay.  You
can find the directive that Medicare sent out on this on the AOPA web site
under www.aopanet.org.  Look under Reimbursement, then select
Reimbursement Policies/Information and select Pre-Discharge Delivery of
DMEPOS.
  This regulation, which should be used with some discretion, does not
technically apply to private payors, however some may be following Medicare
guidelines.
Kathy Dodson
Director of Reimbursement Services

Steve,
Medicare does in fact have a two day rule concerning the delivery of
devices.  To my knowledge there are some restrictions, for example post
surgical devices.  You need a thorough understanding of those regulations, a
good working arragement with your hospital and processes in place to assure
compliance.  It is a workable arrangement within the confines of the
regulations if handled properly.
Eileen  Levis
Administrator
Harry J. Lawall & Son, Inc