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Second Opinion

Learn about policy issues important to medical schools and teaching hospitals, with Executive Vice President Atul Grover, M.D., Ph.D.

Washington Highlights

CMS Issues New Proposed Rule on Part B Inpatient Billing in Hospitals

March 22, 2013—The Centers for Medicare and Medicaid Services (CMS) March 18 issued a proposed rule, Medicare Program; Part B Inpatient Billing in Hospitals, that would allow additional Medicare Part B payment when a Part A claim is denied because a hospital inpatient admission is found not to be reasonable and necessary.

Under the proposed rule, Medicare would accept new, timely filed Part B inpatient claims and provide payment for all reasonable and necessary Part B inpatient services, except those that by statute, Medicare definition, or coding definition specifically require an outpatient status (such as observation services and therapy).  If adopted as proposed, a hospital would have to submit the Part B inpatient claim within one year of the date of services to be timely filed.  Also, a hospital would not be able to simultaneously appeal the Part A inpatient claim and file an inpatient claim under Part B.

Also on March 13, CMS Acting Administrator Marilyn Tavenner issued an Administrator’s Ruling (CMS-1455-R) to address the significant number of pending appeals of Part A hospital inpatient reasonable and necessary denials. Under the Administrator’s Ruling, Medicare will pay for all Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted as an inpatient (except for services requiring strictly outpatient status), until the proposed rule, Medicare Program; Part B Inpatient Billing in Hospitals, is finalized.

The Ruling only addresses Part A claims denied because the inpatient admission was not reasonable and necessary, and only applies until the proposed rule, Medicare Program; Part B Inpatient Billing in Hospitals, is finalized.

Contact:

Allison M. Cohen, J.D., LL.M.
Senior Policy and Regulatory Specialist
Telephone: 202-862-6085
Email: acohen@aamc.org

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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.


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For More Information

Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806
Email: jkleinman@aamc.org