Q&A: Self-Denials After Part A Payment

Q: Can you self-deny a claim after you've already received Part A payment for it?

A: Yes. Even if you have already received payment, it is your responsibility to always ensure the ­services billed to Medicare were correctly paid and any overpayment refunded. If upon review you believe there is a case that did not meet medical necessity requirements, even though you had already billed it to Medicare and received payment under Part A, it is your responsibility to correct that overpayment. This would happen if the patient is here and nobody flags the stay as possibly not appropriate or medically necessary under Part A while the patient is here and then discharges the patient. The claim would be submitted as usual and paid. Then, subsequently, the UR committee may be looking at cases that were one-day stays or meet other criteria they have set up for review, and upon review they ­determine the case does not meet medical necessity requirements for payment under Part A. Once that determination is made, the hospital would have to refund the Part A payment to Medicare by submitting an adjustment claim on a TOB 110. When that processes, and the hospital refunds the patient any copay or deductible that may have been collected, they can then proceed with the inpatient Part B billing. This makes the process more complicated than if the original Part A claim is a no-pay claim (TOB 110), and it takes a little longer to get through, but in the end the result is the same: no Part A payment and instead payment under Part B through billing an inpatient Part B claim.

This Q&A was answered by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.

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