Wiki hospital POS help

[toniboni]

If our practice pre-certed a surgery as inpatient (this POS is required by the insurance company), but the hospital's documentation shows POS to be outpatient. Do we still have to match our claim's POS to the hospital's POS? Or can we bill the surgery as inpatient? This doesn't affect our reimbursment as it would be the same whether it's in or outpatient. But since the pre-cert was for inpatient, the insurance company will not pay our claim. (This has nothing to do with CMS or a CMS claim.)
Please help as I have not had this type of issue come up before. I know this may get a lot of "view", but I really, really need an answer (& I promise not to quote you!) .
Thank you.

 

[mitchellde]

You cannot bill it as inpatient if you in fact performed the procedure outpatient. So the question is was hte patient admitted as an inpatient? If they were not admitted prior to the procedure being performed then you may not use an inpatient POS. You can however appeal and explain why the procedure was performed outpatient instead of inpatient, or you can appeal and show the admit record which shows the hospital billed incorrectly.

 

[toniboni]

Thank you so much for the help, Debra. I had a feeling this was going to be the issue. However we needed to get a second opinion for our back office billing staff. I've seen your answers to questions posted before and I find you to be very knowledgeable. I am so glad you responded. Have a great day!
T.

 

[cmranvik]

From an insurer's point-of-view, I don't see why the insurance company would deny the surgery fee as long as it was for the same surgery that was pre-certified. I'd definitely appeal since the outpatient surgery saved money by eliminating inpatient charges. Also, the patient may not have met admission criteria.