Today, CMS held its Open Door Forum related to the CMS A/B Rebilling Demonstration. General information related to the CMS call is available at http://go.cms.gov/cert-demos. This website includes a Frequently Asked Question document, slides related to the call, and the enrollment application.
CMS outlines the process for the rebilling demonstration as follows:
Once a provider submits a short stay inpatient (Part A) claim, defined as two days or less within the same spell of illness • Inpatient admission is deemed not medically necessary by MAC, Recovery Auditor, CERT, or Provider self-audit (should have been outpatient)
• Denials and voluntary refunds are for full amount • If part of the demonstration, providers can re-bill for all outpatient services – Payment will be made at 90% after co-insurance and deductible.
The demonstration will be limited to 380 hospitals, accepted on a first come, first served basis. The 380 hospitals will be broken down as follows:
• 80 “Large Facilities,” defined as 300+ beds • 120 “Moderate Facilities,” defined as 100-299 beds • 180 “Small Facilities,” defined as fewer than 100 beds
Applications will be accepted beginning December 12, 2011 at 2:00 p.m. Applications will not be accepted prior to this. If a hospital is not one of the first 380 hospitals to apply, they will be placed on a waiting list. Additional information regarding this process is available at http://go.cms.gov/cert-demos.
There are two provisions of this demonstration project that may prove particularly troubling to hospitals, and may give some hospitals pause prior to applying to participate in this demonstration:
• If a hospital chooses to participate in the demonstration program, then the hospital must agree not to appeal any Part A short stay inpatient claim (defined as a claim for inpatient hospital services 2-days or less).
• Also, if the hospital chooses to re-bill, it may not re-bill for observation services.
Given the above considerations and also given many hospitals’ success rate during the appeals process, many hospitals may choose not to participate in this demonstration.
For more information regarding RACs or Medicare appeals, please visit The HLP website or contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510.