Noridian Healthcare Solutions, LLC. Inappropriately Paid Hospitals' Medicare Claims Subject to the Postacute Care Transfer Policy in Jurisdiction 2.

摘要

Medicare's postacute care transfer policy distinguishes between discharges and transfers of beneficiaries from hospitals under the inpatient prospective payment system. Consistent with the policy, Medicare makes full Medicare Severity Diagnosis-Related Group (MS-DRG) payments to hospitals that discharge inpatients to their homes or certain types of health care institutions, such as hospice settings. In contrast, for specified MS-DRGs, Medicare pays hospitals that transfer inpatients to certain postacute care settings, such as home health care and skilled nursing facilities, a per diem rate for each day of the stay, not to exceed the full MS-DRG payment for a discharge. Therefore, the full MS-DRG payment is either higher than or equal to the per diem payment dependent on the patient's length of stay in the hospital. CMS requires hospitals to include a two-digit patient discharge status code on all inpatient claims to identify a beneficiary's status at the conclusion of an inpatient stay. Whether Medicare pays for a discharge or a transfer depends on the patient discharge status code. In 2004, CMS implemented Common Working File (CWF) edits to identify transfers improperly coded as discharges. Specifically, if a postacute care claim is processed and paid before a corresponding inpatient claim is processed, prepayment edits for inpatient claims are designed to reject the incoming inpatient claim. However, if an inpatient claim is processed and paid before a corresponding postacute care claim is processed, postpayment edits are designed to (1) adjust the claim automatically by canceling the original inpatient claim and (2) identify the overpayment. In both instances, the hospital may submit an adjusted claim with the appropriate discharge status code to receive the per diem payment.