Want to Get Paid for Inpatient Admissions? Follow CMS Certification Requirements.

In its final regulations for the 2014 Inpatient Prospective Patient System, the Centers for Medicare and Medicaid Services emphasized the importance of physician certifications. Under the regulations, Medicare will only pay for an inpatient admission if a physician certifies the medical necessity for the stay. The first piece of such certification is for the physician to complete an inpatient order when he or she expects that the patient will require a stay that crosses at least two midnights.

In addition to the order, physician certification for the inpatient stay also must include the following information:

  • Certification that the inpatient services were ordered in accordance with the Medicare regulations governing the order;
  • The reasons for either: (1) hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study; or (2) special or unusual services for cost outlier cases under the inpatient prospective payment system;
  • The estimated time the beneficiary requires or required in the hospital;
  • The plans for post hospital care, if appropriate, and as provided in the Medicare regulations; and
  • For Critical Access Hospitals (CAHs), the physician must certify that the patient will reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.

Physicians must complete all certification for the inpatient stay prior to patient discharge. In order to help ensure Medicare payment for inpatient admissions, hospitals should educate physicians on the importance of certifications, and provide assistance to physicians in gathering necessary documentation.

CMS has prepared a guidance document about hospital inpatient admission orders and certification. For more information about inpatient admission certification, please contact Casey Moriarty.

Tacoma Physician Group Pays $14.5 Million To Settle Medicare Over-Billing Allegations

Sound Physicians, a Tacoma-based, national physician group that employs more than 700 hospitalists, paid $14.5 million to settle claims that it over-billed Medicare.  Former Sound Physicians’ employee Craig Thomas filed a whistleblower lawsuit under the qui tam provisions of the False Claims Act.  The lawsuit alleges that the company knowingly submitted inflated claims where documentation did not support the level of service billed.  Qui tam relators are generally entitled to 15 – 30 percent of the government’s recovery; Thomas will receive $2.7 million, or approximately 18.6%, of the $14.5 million settlement.  The settlement represents one of several recent settlements between the government and health care providers under the False Claims Act.

To read the Department of Justice press release click here.

To read qui tam Relator Craig Thomas’ statement click here.

For more information about government investigations, Medicare compliance, or the False Claims Act, please contact Adam Snyder.