Patent got HMO middle of the month - where to file a claim


Q: My patient enrolled in a Medicare Advantage (MA) plan during the middle of the inpatient hospital stay. Who should I bill?

A: When a patient enrolls or disenrolls in a MA plan during his/her inpatient stay, the following factors will determine whether to bill the MA plan and/or “traditional” Medicare:

1. The hospital provider receives prospective payment system (PPS) payments, or is exempt from PPS payments, or is a non-PPS provider; and

2. The date of enrollment/disenrollment with the MA plan

Inpatient PPS provider billing guidelines

The patient’s entitlement status at admission determines liability for inpatient acute care hospitals, inpatient rehabilitation facilities (IRFs), or long term care hospitals (LTCHs) that receive PPS payments.

If the patient was not enrolled in the MA plan at the time of admission and enrolls before discharge:

• Bill the entire inpatient stay to Medicare for payment
• MA organization is not responsible for payment

If the patient is enrolled in an MA plan at the time of admission and disenrolls before discharge:

• Bill the entire inpatient stay to MA plan for payment, and,
• Submit a no-pay claim to Medicare to report the patient’s inpatient utilization days


Exempt PPS inpatient provider billing guidelines

Providers that are inpatient children hospitals, cancer hospitals, and psychiatric hospitals/units exempt from PPS must split bill the appropriate coverage portion of the patient’s inpatient stay with Medicare and MA plan.

Example:

The patient is admitted on September 28 and discharged October 13, and enrolls in an MA plan effective October 1. Split bill as follows:

• Bill Medicare for dates of service September 28 through September 30; and,

• Bill MA plan for dates of service October 1 through October 13, and include necessary supporting documents; and

• Submit a no-pay claim to Medicare for dates of service October 1 through October 13 to report the patient’s inpatient utilization days

Non-PPS inpatient provider billing guidelines

Inpatient hospitals that do not receive PPS payments must also split bill and may only bill the MA plan for dates of service that fall within the coverage period enrollment and disenrollment dates.


Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare or the MA plan?

A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.

While a hospice election is in effect, certain types of claims may be submitted to the MAC, by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:

• Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice

• Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition

• MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked

Example:

Beneficiary’s hospice election period ended on 1/10/YY
Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY
Bill the MA plan for claims for dates of service 2/1/YY and beyond



Q: How do I determine if a patient is enrolled in a Medicare Advantage (MA) plan, previously referred to as a Health Maintenance Organization (HMO)?

A: It is recommended you obtain eligibility and benefit information prior to rendering services to patients. Click here for ways to verify eligibility. You can also do the following:

• Ask patients if they have recently enrolled in any new health insurance plans.
• Request to see a copy of all of their health insurance cards.

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