Let’s discuss the importance of physician advisor services. According to a report issued by the Department of Health & Human Services, the Office of the Inspector General reviewed a case involving University of Pittsburgh Medical Center Presbytarian Shadyside (the University). The final report is entitled Review of Medicare Acute Care Inpatient Same-Day Readmissions at University of Pittsburgh Medical Center Presbytarian Shadyside Hospital. The full report can be found at http://oig.hhs.gov/oas/reports/region3/31000013.pdf.

Title XVIII of the Social Security Act established the Medicare program, which provides health insurance cove rage to people aged 65 and over, people with disabilities, and people with end-stage renal disease. Medicare Part A provides inpatient hospital insurance benefits and coverage of extended care services for patients who have been discharged from the hospital.

Importance of Physician Advisor Services

Section 1886(d) of the Act established the prospective payment system (PPS) for inpatient hospital services. Under the PPS, The Centers for Medicare and Medicaid Services pays hospital costs at predetermined rates for patient discharges.

Medicare in all caps with the symbol of health. Don't underestimate the importance of physician advisor services and medicare.

Don’t underestimate the importance of physician advisor services and medicare.

The Medicare Claims Processing Manual, Pub, no. 100-04, chapter 3, section 40.2.5, states that when a patient is discharged/transferred from an acute care PPS hospital, and is readmitted to the same acute PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.

The University, during the calendar years 2008 and 2009, received $913,355 for 47 readmissions for which an inpatient was discharged and readmitted the same day. A prior OIG report found that same-day provider readmissions for which a beneficiary was discharged to another provider after the initial admission and prior to being readmitted were vulnerable to billing errors. That review found that 41 of 73 readmissions were billed incorrectly.

The review’s objective was to determine whether the University billed same-day readmissions in accordance with Federal requirements. The following were conducted in conjunction with the review: (1) reviewed applicable Federal laws, regulations, and guidance; (2) extracted the University’s inpatient paid claims data from CMS’s National Claims history file; (3) identified 47 inpatient same-day readmissions; (4) selected 27 readmissions for which the patient was discharged to another provider and subsequently readmitted; (5) reviewed the admission and readmission records, itemized bills and readmission advices; (6) discussed the incorrectly billed readmissions with the University to determine the underlying causes of non-compliance with Medicare requirements; and (7) calculated the correct payments for those readmissions requiring adjustments.

As a result of the review, 7 of the same-day readmissions were billed incorrectly resulting in $25, 547 in overpayments by Medicare. These 7 should have been combined with the initial hospital stays in single claims for continuous stays rather than as separate claims for separate stays. The overpayments occurred because the University did not have adequate training to review same-day readmissions and prevent incorrect billings.

The recommendations set forth by the OIG were: (1) refund to the Federal Government $26,547, (2) strengthen training to ensure that same-day admissions are reviewed and billed correctly, and (3) cases are sent to physician advisors review.

Non-compliance with Medicare can be very costly. BHM Healthcare Solutions offers physician advisor training and physician advisor services. For more information, go to the BHM Physician Advisor page. For a free consultation, please call 1-888-831-1171.

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