MCare Solutions has been instrumental in convincing intermediaries to allow recoveries for its clients going back four or more years in all states. For example, the recoveries for a hospital with 10,000 annual Medicare IP discharges over a four year period would typically range $1 million – $2 million. Factors influencing recoveries generally include case mix, internal processes, ownership of a SNF or HHA, and multiple year opportunities.
The MCare Solutions Position
MCare's position, as presented to CMS, was that the original status codes were assigned based on the medical record data that existed at that time, which indicated that the patient was being transferred to a post acute care provider. The hospital has subsequently learned that the patient was not transferred to the post acute care provider as was reflected by the original status code. Thus, these claims contain errors and must be corrected. After a long, 18+ months "discussion," MCare prevailed. Hospitals may now conduct 4-year retrospective review and 4-year retroactive rebilling of TDRG claims in all 50 states!
The CMS Response, February 2009
The Medicare Claims Processing Manual (IOM 100-4) and the federal regulations provide that the proper time limit for requesting an adjustment to claim, where the adjustment corrects or supplements information previously submitted on a timely claim, is not one year, but the period within which a reopening may be requested (or four years).
For references, please see the Medicare Claims Processing Manual Chapter 1 sections 70.5, 130.1.1., Ch. 34 sections 10.4.1, 10.6.2., and 10.11, and 42 C.F.R. §405.980(c)(2).
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