Responses to inquiry on billing hospitals for o & p

Responses to inquiry on billing hospitals for o & p

Debra Adams

1/8/2014

Here are the responses - unfortunately, there is not a clear cut answer.  It may be the best case scenario is to clarify the billing parameters for Medicare and Medicaid patients to the hospital and then perhaps to take back over the direct billing of other insurance on a case-by-case basis as on of the respondents is already doing.

Thanks for all the comments and  here are the results:



The hospital has to pay for the devices if it's Medicare,
according to the PPS regulations.  I strongly suggest you check with each
of your individual insurers and ask them if they will allow this
practice.  Many of our insurers expect the hospital to pay for the devices
even though the hospital has said they want us to bill the insurer.  We've
had our hospital contracts revised in a couple of cases to allow us to bill the
hospital once we informed them we can't bill the insurer.  Remember, some
of this is just bullying stall tactics that the hospitals will try to use to
save money.  Just make sure you have all the facts first before making a
decision. 


*******************
 
I have been dealing with a purchasing agent in my local
hospital for approx. 2 years on this issue. Even though I've thoroughly
explained and given him the Medicare policy in writing, he still refuses to
pay. I'm still working towards a written contract with the hospital but
don’t think that's going to happen. I have even appealed to the compliance
officer at the hospital (who is agreement with my interpretation of the
Medicare law) but still have a difficult time getting paid for my services
on in-patient Medicare claims. I have been billing 3rd party pay sources
without too much trouble. It does get interesting when an authorization is
required i.e. W/C.  At that point I make sure that the ordering physician
is
well aware of the hospital policy and that a delay in services is
probable. You would think that if the Dr.'s are aware of the hospital policy
that they may work to change it, but it hasn't happened in my case. I've
even asked them to take and discuss it before the physician hospital board
and I believe it has several times but has been tabled without a
decision
being made. I guess because it happens infrequently that it's not a huge
issue here...and I guess I could refuse services to cause an issue, but
haven’t been willing to this point of making my referral sources mad. Please
let me know if you find someone that has an answer to this ever growing
issue.
 
 
Yes, we have been dealing with this for well over a year.
All Medicare cases are paid directly by the hospital, as is required by law.
However, all other insurance we bill as if they were seen in the office. That
does cause some problems as you can well imagine. For example, last week, we
had a call for an LSO post surgical from a very good referral source. Problem
was  he has Cigna whom we have dropped the contract with due to the
obvious reasons I am sure you are aware. (crappola reimbursement, late pay
etc). Other times, we are required to get pre auths on such insurance as
Humana. We work hard at dealing with the carrier to let them know this is a
hospital patient and delays will cost them even more. Anyway, sure isn't like
the good old days. Hope it works ok for you. But you are right in letting them
know they have no choice but to pay from their perdium (sp) that they receive
from medicare on those cases.
 
Medicare and Medicaid, and any Medicare Advantage plans, all
have to be paid by the hospital.  That is rule of the Government. 
The hospitals are paid by rug rates and MDS scores and in patient per deim
fees.  These services are included in the pay to the
hospital.  Now, Commercial carriers, workmen's Comp, can be handled
by billing directly to the carrier.  If and item needs authorization and
you cannot obtain one in a timely manner..then the hospital will have to be
billed and you will have to get a PO from the hospital
so that you get paid.  If you are being mandated to bill outside of the
above criteria, I would request a meeting with that hospital and enlighten
them on the rules of Medicare and Medicaid hospital billing.
 
All the rules are in the Medicare Manual..and you can call
your Medicare carrier and have them walk you straight thru to the rule that's
written in the manual.
 
Also..just a little note here..when doing business with the
hospitals, offer them a discount off of the Medicare fees schedule, so they
will see a discount.  WE offer 20-25% off of billed item.  Makes for
good business partners, and if the hospitals do not know how to bill for the
items..our hospitals usually bill under a misc code..of surgical supplies..so
they do get their money back one way or the other..they are no taking a loss. 
 
 
You may consider including
verbage such as for home use for the AFO. We know that the AFO is
necessary before they can discharge the patient. Why not have the doctors start
writing orders for the afo and such to be included in discharge planning. They
can even request trial fitting at hospital to ensure proper fit and for
training in donning and doffing, but they should order it for home. I have even
had snf's order a set of ots afos (provided at my cost) that demonstrate that
they have a complete set at their facility and only need the custom
early for training purposes.
 
With that said, you may have found a win-win for the hospital and
might suggest that they involve your company in troubleshooting and locating
other areas for cost saving. As much as your local hospital must write off from
the insurance companies, they could probably use your expertise in this
area.  If not, then Hanger probably will offer to help soon...
 
 
You either follow Medicare and other insurances guidelines,
or you keep doing business the old way and eventually go out of business. You
may lose some business NOW but stay afloat in long run. Have no doubt, whoever
your hospital will chose to switch to will have exactly same problem.
What you need to do is to make solid inservice with hospital financial people
and lead practitioners/nurses/PTs and make situation loud and clear to them,
emphasizing that rules are the same for everyone and
if someone promises them something different, they either do not know what they
are doing or going in for a quick buck grab and run situation.
We have never been able to bill hospitals for inpatient
services for any other payer source than Medicare and Medicaid. Don't know or
think this is regional issue. We are in northeastern Ohio.
 

That is a new one, although not entirely surprising, given that most hospital
activity is on a per diem basis, and people have found any number of creative
ways to bypass the per diem limits.  We have not heard of anything like
this happening, but it will create a lot of problems.  As with Medicare,
how that will work will depend entirely on the policies of your payers, but I
suspect that they are not just going to say, OK, go ahead and bill us directly
now.  In the near term, for you, it would seem that all you can do is
decline to provide services until you determine who is going to pay for
them.  Given that this is a significant policy change, I don't think that
clear answers and policies are going to be available very quickly from the
payers, but I wouldn't do anything until I had a payment system in
writing.  For some of the payers you mention, providing services will be
effectively impossible, unless you want to give your services away.  The
hospital has put you in a difficult spot, because they are probably assuming
that the payers will just start paying, ignoring existing policies, but will
still expect you at their beck and call. 

Having read all of the ACA, I don't think this is related, other than possibly
the hospital taking advantage of the timing of the official start of the ACA to
make some changes which may be blamed on the ACA.  For one hospital to
make a change like this is unusual, to say the least, because they cannot
dictate payer policies.
 
 
Our facility has been billing for two major hospitals and
one of them we have been able to bill directly for years, with the exception of
Medicare. They are still liable unless they are going home and the brace is
needed for discharge.