Ambulatory Coding & Payment Report
Reader Question: Check Up On Medicare
Question: What can hospitals do to make sure theyre being reimbursed correctly by Medicare under APCs?
Oklahoma Subscriber
Answer: Hospitals are going to have to enter a new world in which they will have to post payments by line item for ambulatory payment classifications (APCs) when the payer is Medicare. The explanation of benefits (EOB) from Medicare to the hospital should provide the hospital with the APCs that the program feels the hospital is entitled to, and they also will tell the hospital how much it is permitted to charge the Medicare beneficiary as a co-payment for each APC individually, as well as the aggregate beneficiary co-payment.
Because hospitals are permitted to reduce their bill to the Medicare beneficiary to the minimum co-payment on some chosen APCs as well as on all APCs, hospitals are going to need a methodology to determine independently if the program has grouped and assigned all applicable APCs correctly, as well as independently determine if Medicare has figured the beneficiary co-payments correctly.
Both Medicare and hospitals may make mistakes. Developing APC Grouper software and including an itemized list of all the hospitals legitimate charges (if the payer was other than Medicare), may prove incredibly beneficial.
If the software also calculates the correct Medicare program payment and beneficiary co-payment for each APC and aggregates the amounts into total payments expected from the Medicare program as well as from the beneficiary, the hospital would benefit greatly. If the software also provides the hospital with the CPT codes and ICD-9 codes that are billed on the physicians claim to Medicare, this also would aid the hospital to select their CPT codes.
- Published on 2000-07-01
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