Health Information Technologies and Processes

Insurance Company telling Bill as Observation and Order says Inpatient

  • 1.  Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 03-26-2020 10:54
    We have more and more insurance companies that are requesting we bill the patient as an outpatient, our order reflects inpatient.  Does anyone have any suggestions about this.  Our PFS can bill them without changing the patient status or the record so it reflects what the order says.  In working with UR they share that other facilities do this all the time. I am thinking we need this information in writing and a policy of how and when to do this.  Has anyone else encountered this?  Do you have a policy or best practices you would share

    ------------------------------
    Kimberle Johnson
    [Director Privacy and Compliance Officer]
    Campbell County Health
    ------------------------------


  • 2.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 03-27-2020 08:05
    If anyone has a process I too would love this.  We struggle with this in soooo many ways.  We have generally only charged for the obs hours if there was an actual obs order sometime during their stay.  So if they were ER to OBS to IP, we would bill for the obs hours.  But if they were ER to IP....no obs billing.  One insurance company is actually auditing us on these, which is aggravating to say the least.  Not only did they not approve the inpatient admission...now they are auditing our use of observation hours.

    ------------------------------
    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital
    ------------------------------



  • 3.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-06-2020 12:50
    Unfortunately I believe this is the trend all over.  How we are currently handling this is by having the doctor change the order to observation and documenting "Per name of insurance company direction patient orders have been changed to reflect observation care"  It freaks me out a little when we do it but I feel like we don't have another choice.

    ------------------------------
    Ilene Estabrook
    Him Manager
    ------------------------------



  • 4.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-06-2020 13:17

    We currently are not changing the order, we are just billing as the insurance company ask's us to.  We are leaving the order as written and the account as the order is written but they are change charges to reflect observation care and billing an outpatient claim.  We have started asking for letters reflecting this to be scanned into the record.

     

     

     






  • 5.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-07-2020 07:30
    Billing as an outpatient could present problem for Medicare patient who requires a 3 night inpatient stay to receive skilled facility coverage.






  • 6.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-09-2020 15:44
    Brenda, we are handling the Medicare with condition codes 44 and W2, as the policy states.  Agreed could affect the skilled facility admission.

    ------------------------------
    Kimberle Johnson
    [Director Privacy and Compliance Officer]
    Campbell County Health
    ------------------------------



  • 7.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-07-2020 11:05

    So in Kimberle's case of not changing the order, are you then billing for observation hours based on the time the admission order was written? I have the same question for Ilene as well. We have always just followed the Medicare rules on this and requested a peer to peer to justify the admission which in most cases works but I am interested in hearing how others are handling this. I would also love to see a facility policy on this if anyone has one.

     

    Thank you!

     

    Misty Zink, AAS, RHIT

    COC, CPC, CPCO

     






  • 8.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-09-2020 15:45
    We are using the admit order to being counting the observation hours.

    ------------------------------
    Kimberle Johnson
    [Director Privacy and Compliance Officer]
    Campbell County Health
    ------------------------------



  • 9.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-21-2020 17:03
    Misty,

    When the insurers are stating they would pay it if observation and the provider is willing to change the order we follow the process of carving out observation hours.  We also call the patient and inform them of the status change, reason etc.

    Thanks

    ------------------------------
    Ilene Estabrook
    Him Manager
    ------------------------------



  • 10.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-10-2020 09:53
    Under the Medicare guidelines, knee replacements are treated as outpatient surgery.  Patient may be in hospital for three overnights-as an outpatient.  When patient is released, since they were treated as an outpatient at the acute hospital, under Medicare guidelines they have not met the three overnight stay for skilled nursing care. In some cases, the physician is under the impression the patient has a qualifying acute hospital stay and orders the patient transferred to the skilled nursing facility for rehabilitation services … only for the family to find out the patient does not quality under the Medicare guidelines.

    Legally, how can a physician's order for inpatient acute hospital be changed to an outpatient, after the event?  How can we bill for outpatient services when the physician has provided an inpatient admission order?




    ------------------------------
    Brenda Huntsinger, RHIT, LNHA
    Instructor
    ------------------------------



  • 11.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-07-2020 06:46
    We have actually created a policy and procedure for this, and have a specific form. "Variance from Written Order" Basically the form is "owned" by the UR department and as they find out the insurance company will not pay for Inpatient but will pay OBS - she will fill out the form that says something to the effect of, due to Insurance determination we are billing as observation even though the order indicated inpatient status. That gets scanned to the record and we change the billing - we do not change the order.

    ------------------------------
    Amanda Manning
    Revenue Cycle Manager
    ------------------------------



  • 12.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-09-2020 15:46
    Amanda,

    Are you willing to share a copy of this form.

    ------------------------------
    Kimberle Johnson
    [Director Privacy and Compliance Officer]
    Campbell County Health
    ------------------------------



  • 13.  RE: Insurance Company telling Bill as Observation and Order says Inpatient

    Posted 04-07-2020 09:08
    I'm interested in learning how other facilities are handling/addressing these insurance requests.  I'm interested in receiving a copy of the form being used (to attach to records) or policies that someone may have available.

    ------------------------------
    Nellie M Lunsford, RHIA
    Dir of Compliance Education
    nlunsford@chambershealth.org
    ------------------------------