Medicare Advantage claims and IME

RHirschRHirsch
in BILLING AND CLAIMS
It is my understanding that claims for MA patient inpatient admissions are submitted to the MA plan but also a "informational only" claim is submitted to the MAC with appropriate condition codes and comments and that claim results in the payment of IME money directly from Medicare. My questions-
Does this also include DSH and uncompensated care payments?
If the MA plan denies or otherwise 'downgrades' the claim, does the hospital have to submit a corrected claim to the MAC? For example, if the MA plan disallows an MCC and pays the DRG with a CC, the amount of IME money would drop since that amount is in proportion to the total DRG amount. But how does the MAC know the MA plan disallowed an MCC?

Comments

  • Andrew.ReitenAndrew.Reiten
    Does this also include DSH and uncompensated care payments? 

    No, only the Operating IME is paid on the MAC claim; this amount is also Transfer adjusted.  Also, the requirement is that all MA inpatients need to have shadow claims submitted to Medicare--this can include Distinct Units, CAHs, and other types of inpatients that would not actually receive IME payments--they would receive a 0.00 payment from the MAC.

    I do not think I have seen anything from my MAC or CMS addressing your other questions. 
Sign In to comment.