Medicare providers are expected to work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party is able to reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter.
Full Answer
What does overlap mean in Medicare?
Medicare Payments for Overlapping Part A Inpatient Claims and Part B Claims Overlapping claims can happen when a beneficiary is an inpatient of one hospital and then sent to another hospital to obtain outpatient services that are not available at the originating hospital.
What happens when Medicare identifies an overpayment?
When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments. Medicare overpayments happen because of:
How do I appeal an overpayment to Medicare?
Appeal the overpayment by requesting a redetermination. Payment Options Immediate Payment: Follow the demand payment letter directions. Request Immediate Recoupment: Occurs when Medicare recovers an overpayment by offsetting future payments. Your MAC may recoup a partial payment (for example, a percentage
Can a hospital overlapping with a SNF be billed?
Hospital overlapping with a SNF: The hospital should ensure that they have submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the claim.
What is an overlapping claim?
Overlapping claims can happen when a beneficiary is an inpatient of one hospital and then sent to another hospital to obtain outpatient services that are not available at the originating hospital.
Can you split bill Medicare?
A split/shared visit must be billed under the NPI of the individual who performed the substantive portion of the visit. That individual also must sign and date the medical record.
What is occurrence span code 74?
When a patient is discharged to a swing-bed and is readmitted to the same LTCH within 4-45 days (occurrence span code 74 shows 44 days or less).
What does condition code 51 mean?
attestation of unrelated outpatient non-diagnostic servicesCondition code 51 (attestation of unrelated outpatient non-diagnostic services”) is not included on the outpatient claim. The line item date of service falls on the day of admission or any of the 3-days/1-day prior to an inpatient hospital admission.
What settings allow split shared billing under the new Medicare rules?
The split/shared E/M visit policy applies only to selected settings: hospital inpatient, hospital outpatient, hospital observation, emergency department, and office and non-facility clinics. A split/shared E/M visit cannot be reported in the skilled nursing facility (SNF) or nursing facility (NF) setting.
What is the FS modifier used for?
Modifier FS This modifier is used to indicate the service was a split or shared evaluation and management (E/M) visit.
What is an occurrence code 32?
Occurrence code 32 on a claim signifies that an ABN, Form CMS-R-131, was given to a beneficiary on a specific date. This code must be employed if this specific ABN form is given, and condition code 20 will not be used on the subsequent claim (i.e., no charges will be submitted as non-covered).
What is a Medicare outlier payment?
Medicare makes supplemental payments to hospitals, known as outlier payments, which are designed to protect hospitals from significant financial losses resulting from patient-care cases that are extraordinarily costly.
What is an outlier in medical billing?
by Medical Billing. Definitions. • Cost outlier — an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge.
What does condition code 69 mean?
teaching hospitals onlyCondition code 69 (teaching hospitals only - code indicates a request for a supplemental payment for Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
What is modifier PD?
20. Physician practices or other Part B entities should use Modifier PD (Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days or 1 day) to identify HCPCS codes for services subject to the payment window.
What is the 72 hour rule for Medicare?
The 72 hour rule is part of the Medicare Prospective Payment System (PPS). The rule states that any outpatient diagnostic or other medical services performed within 72 hours prior to being admitted to the hospital must be bundled into one bill.
When is Medicare verification required?
Medicare providers are expected to verify a beneficiary’s Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the beneficiary’s eligibility records also ensures that the facility/agency verifies whether or not the patient is receiving services from another entity that would cause an overlapping situation.
How to transfer a home health plan?
1. Access the patient’s eligibility records in the direct data entry (DDE) system and print and save a copy of the page that validates whether or not the patient is under an established home health plan of care. 2. Contact the transferring agency to arrange for a transfer date. 3.
How long does it take for a hospital to pay for LTCH?
Hospital overlapping with LTCH: When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services.
Can a hospital outpatient overlap a SNF?
Hospital outpatient overlapping a SNF Part A stay: A patient may receive outpatient hospital care during a covered Part A SNF stay. Certain services maybe part of SNF consolidated billing, and therefore payment received for those services, should be made by the SNF to the outpatient facility.
Can a patient receive home health care while in hospital?
Hospital overlapping with home health care: A patient cannot receive home health care while he/she is in an inpatient hospital stay. When the patient is in the hospital that falls within a 60-day episode of care, the home health agency is required to omit those dates from their final (end of episode) claim.
Can a hospital be paid for a transfer?
The transferring hospital cannot be paid for the actual date of transfer. The receiving hospital can be paid for the date of the transfer, but not the date of discharge.
Can ORF and CORF be paid separately?
ORF or CORF overlapping with SNF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF Part A stay in a Medicare certified bed. If therapy services are needed from an ORF or CORF, the SNF and the ORF or CORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF or CORF.
What is overlapping claims?
Overlapping claims can happen when a beneficiary is an inpatient of one hospital and then sent to another hospital to obtain outpatient services that are not available at the originating hospital. Certain items, supplies, and services furnished to inpatients are covered under Medicare Part A and should not be billed separately to Medicare Part B ...
Why is Medicare overpayment?
The payments associated with these claims are considered overpayments because Medicare does not allow separate payment for DMEPOS when a beneficiary is in a covered inpatient stay (Medicare Claims Processing Manual, Ch. 20 01).
Is DMEPOS billed to Medicare?
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries who received DMEPOS items while in an inpatient stay in a hospital should not be billed to Medicare separately. The payments associated with these claims are considered overpayments because Medicare does not allow separate payment for DMEPOS ...
What happens if Medicare overpayment exceeds regulation?
Medicare overpayment exceeds regulation and statute properly payable amounts. When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments.
What is an overpayment?
An overpayment is a payment made to a provider exceeding amounts due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require CMS recover overpayments. This fact sheet describes the overpayment collection process.
What is reasonable diligence in Medicare?
Through reasonable diligence, you or a staff member identify receipt of an overpayment and quantify the amount. According to SSA Section 1128J(d), you must report and return a self-identified overpayment to Medicare within:
What is SSA 1893(f)(2)(A)?
SSA Section 1893(f)(2)(A) outlines Medicare overpayment recoupment limitations. When CMS and MACs get a valid first- or second-level overpayment appeal , subject to certain limitations , we can’t recoup the overpayment until there’s an appeal decision. This affects recoupment timeframes. Get more information about which overpayments we subject to recoupment limitation at
How Do I Pay My Premium?
For Part B, your premium will be taken out of your Social Security check once you start collecting on Social Security. Before that time, or if you don’t qualify for Social Security, you can pay your Part B premium online using a debit card, credit card, or a connected bank account.
What To Do If There Is A Medicare Billing Error, Or You Suspect One Occurred
Billions of dollars move around the government, hospitals, and the population’s collective pockets every year for Medicare coverage. Billing issues can arise from all this money moving hands. In fact, a 2017 report said that there were about $36 billion worth of billing errors that year.
When is Medicare verification required?
Medicare providers are expected to verify a beneficiary’s Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the beneficiary’s eligibility records also ensures that the facility/agency verifies whether or not the patient is receiving services from another entity that would cause an overlapping situation.
How to transfer a home health plan?
1. Access the patient’s eligibility records in the Direct Data Entry (DDE) system and print and save a copy of the page that validates whether or not the patient is under an established home health plan of care. 2. Contact the transferring agency to arrange for a transfer date. 3.
How long does it take for a hospital to pay for a LTCH?
Hospital overlapping with a LTCH: When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services.
What happens if a patient is readmitted on the same day for symptoms related to prior admission?
If the patient is readmitted on the same day for symptoms related to prior admission then the facility needs to combine the bills to create one continuous stay. The other facility must bill the hospital under arrangement.
Can an HHA provide services to a patient?
The HHA cannot provide services to the patient while he/she is in an inpatient facility. The HHA omits any dates of service from their claim that fall on the days between the admission and discharge dates for an inpatient facility. Reference: CMS IOM, Pub. 100-04, Chapter 10, Section 30.9.
Can a hospital be inpatient and outpatient?
Hospital overlapping with outpatient services: A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim.
Can a hospital outpatient overlap a SNF?
Hospital outpatient overlapping a SNF Part A stay: A patient may receive outpatient hospital care during a covered Part A SNF stay. Certain services maybe part of SNF consolidated billing, and therefore payment received for those services, should be made by the SNF to the outpatient facility.
What to do if your provider won't stop billing you?
If the medical provider won’t stop billing you, call Medicare at 1-800-MEDICARE (1-800-633-4227) . TTY users can call (877) 486-2048 . Medicare can confirm that you’re in the QMB Program. Medicare can also ask your provider to stop billing you, and refund any payments you’ve already made. 3.
How to contact CFPB about debt collection?
If you have a problem with a debt collector, you can submit a complaint online or call the CFPB at (855) 411-2372 . TTY/TDD users can call (855) 729-2372 . We'll forward your complaint to the debt collection company and work to get you a response from them.
Can you get a bill for QMB?
If you’re in the QMB Program and get a bill for charges Medicare covers: 1. Tell your provider or the debt collector that you're in the QMB Program and can’t be charged for Medicare deductibles, coinsurance, and copayments.
Is Medicare billed for QMB?
The Centers for Medicare & Medicaid Services (CMS) has heard from people with Medicare who report being billed for covered services, even though they’re in the QMB program.