CMS reminds acute care facilities of outpatient payment rules for inpatients

CMS published Special Edition MLN Matters 17033 on December 6 as a reminder that it will not pay acute care hospitals for outpatient services provided to beneficiaries who are covered under a Part A inpatient stay at a separate facility.

Examples of these separate facilities include long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), inpatient psychiatric facilities (IPF), or critical access hospitals (CAH).

Medicare may not reimburse for acute care services including outpatient surgery and laboratory work if the beneficiary receives those services when inpatient at a facility other than the acute care hospital. Instead, the acute care hospital should seek reimbursement for the outpatient services it provided under arrangements with the LTCH, IRF, IPF, or CAH. The acute care hospital should refrain from charging the beneficiary a deductible or coinsurance for services provided in this manner.

Medicare system edits look at claims to identify whether a covered Part A inpatient stay for a beneficiary was processed on the same date of service as an outpatient claim for the same beneficiary on the same date. If Medicare reimbursed a facility for an inpatient stay and then received an outpatient claim with the same date of service, it would deny the outpatient claim.

If by chance Medicare received and paid the outpatient claim before receiving the inpatient claim, Medicare Administrative Contractors would then recover the outpatient payment and request that the facility providing outpatient services reimburse the beneficiary for any deductible or coinsurance.