You Be the Expert: Bundling All Payers

Question: Should facilities bill all payers according to APCs? My concern is that well lose reimbursement, especially for items such as supplies and medications. Ive been told that Medicare and commercial insurance must be billed the same. Is this the case, or does the price just have to be the same?

M. Koch
Massac Memorial Hospital, Metropolis, Ill.

Test your knowledge. Determine what you would do in this situation before looking at the box below for the answer.



Answer: You do not have to bill different payers in the same way. You cannot however, charge individual payers different prices for the same procedure. Your facility is losing reimbursement from non-OPPS payers by charging according to APC regulations. APCs bundle many procedures into one payment that other carriers might very well pay for separately.

Under OPPS, bill for every service and supply you provide, regardless of its status indicator under APCs. If you do not charge for these items, you are losing revenue from commercial payers as well as Medicare. This concept has confused many hospital financial planners who have tried to change the charge strategy to match the HCFA payment strategy. The best solution is to adjust your existing charge mechanisms to include the appropriate CPT/HCPCS codes and modifiers to selected APCs services. This means you should adapt your existing charging to include APCs, not exclude all other carriers.

- Published on 2001-04-01