One simple file can recover all the Medicare underpayments that result from inpatients’ decisions not to receive the recommended post-acute care after discharge.
Underpayments are likely to go unnoticed without retrospective review of each and every discharge within the list of the 275+ Diagnostic-Related Groups subject to the Centers for Medicare and Medicaid Services’ Post-Acute Transfer Rule. Unless a specific audit is conducted for these cases the revenue loss will continue to grow!
Medicare Transfer Rule
Per CMS Post Acute Transfer (PAT) Policy: If the patient’s length of stay was more than one day less than the geometric length of stay for the DRG, the hospital receives a full DRG payment rather than the per diem rate. That is, if the patient did not receive the expected post-acute care or the post-acute care provider is unable to submit a claim to Part A there is opportunity to capture additional revenue for the hospital. And the opportunity includes a retrospective filing period of four (4) years. CMS takes the position that it is up to the provider to identify and correct the claims subject to these underpayments.
Automation plus Verification
Medidal’s Transfer Recovery Service™ performs an automated, detailed variance search of 100% of claims subject to the Transfer Rule. Based on a minimal data set (only 15 fields), our software processes the Medicare inpatient discharges for up to 4 prior years and identifies claims in the Common Working File (CWF) that likely qualify for additional payments per the PAT Policy. Due diligence is completed through direct contact with SNF, HHA, and FI/MAC to assure 100% of recommended changes to the discharge status code are appropriate. A summary of the recommended adjustments/corrections is submitted for review by the provider. Once approved, Medidal completes the adjustments in the Fiscal Intermediary Shared System (FISS) and monitors the claims to ensure timely payments.