PDPM CLAIM CORRECTION WHEN BENEFICIARY LEAVES MEDICARE ADVANTAGE

CMS said it will fix a glitch in the new Patient-Driven Payment Model (PDPM). The American Health Care Association (AHCA) said SNF PPS Part A claims were not being paid day-1 variable per diem rates when a beneficiary switched from Medicare Advantage (MA) to fee-for-service Medicare Part A during a stay.

AHCA said it reported to CMS that this was inconsistent with current policy.  CMS agreed and on May 8 published a change request to the Medicare Administrative Contractors (MACs) to update the claims processing systems retroactive to October 1, 2019. A summary of the changes is posted in this MLN Matters article. Although this is retroactive, the systems changes will not occur until October 5, 2020.

Providers should notify billing staff that the MACs will adjust any improperly adjusted SNF PPS claims related to a beneficiary switch from MA to fee-for-service during a stay only if brought to their attention, so that the prior days count is corrected to exclude the MA days, the association said.