Proposed Rule for Part B Rebilling

on Tuesday, 02 April 2013. All News Items | Billing

Last week we discussed CMS Ruling 1455-R which allows rebilling of all reasonable and necessary Part B services provided to a hospital inpatient when a Medicare review contractor denies the Part A inpatient admission as not reasonable and necessary. We noted that the Ruling is only temporary until CMS’s proposed rule is finalized. This week we would like to examine the differences between the requirements of the ruling and the proposed rule.

Both revise the Part B inpatient billing policy to allow payment of all hospital services that were furnished and would have been reasonable and necessary if the patient had been treated as an outpatient, rather than admitted as an inpatient, except for those services specifically requiring an outpatient status. The proposals do not change the 3-day payment window policy, which already allows for a Part B outpatient claim to be submitted for services provided during the 3-day window in the event that there is no Part A coverage for the inpatient stay.

There are two major differences between the Ruling and the Proposed Rule:

Hospital Self-Audits of Medical Necessity of Inpatient Admissions

  • The Ruling does not apply to inpatient admissions determined by the hospital to not be medically necessary, such as during UR or other internal review.
  • The Proposed Rule applies when a hospital determines under Medicare’s utilization review requirements that a patient should have received hospital outpatient rather than hospital inpatient services, but the patient has already been discharged from the hospital (hospital “self-audits”). In these instances the hospital would submit a no-pay/provider liable Part A claim and a Part B inpatient claim under the requirements of the proposed rule, which allows billing of all reasonable and necessary Part B services (beyond those currently billable as “Part B” only services).

Timely Filing Requirements

  • The Ruling allows Part B billing past normal timely filing limitations as long as it is within certain other timelines.
  • The Proposed Rule requires that all Part B inpatient and outpatient claims be submitted within the normal timely filing period, which is within one calendar year after the date of service.

The proposed rule also asks for comments on issues relating to the Medicare beneficiary’s liability for Part B copayments and deductibles under the new requirements, noting that it is possible a patient will have a greater financial liability under Part B than they would have had under Part A. There is also detailed discussion in the proposed rule concerning outpatient services that require an outpatient status, types of hospitals covered under the rule, and appeals procedures. MMP, Inc. recommends hospitals carefully review the proposed rule and submit comments if you do not agree with CMS’s decisions. Comments will be accepted on the proposed rule until 5:00 pm on May 17, 2013.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it. .




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