CMS Questions- From Emory
<p>Out of network Part C members if they come to our hospitals and we treat what do we get paid. If we terminate a plan what real impact does it have on that plan if their members can still come to us and we get paid.
·         UR/UM Terms it is very difficult to address this since many seem to apply combination of Medicare rules and their own
o   Two Midnight
o   TOB Termination of Benefits notice when plan does not continue to pay for a stay
o   Time to pay clean claim
o   Definition of clean claim
o   What Medical Necessity Criteria is used
o   Take back of denials
o   Requirement to respond to authorization request – preadmit and continued stay
o   Condition code 44 ie patient status obs vs inpatient span code 72
o   MSP requirement
·         Bad Debt – Balances not paid by the member
·         Sequestration Reductions
·         HAC reductions and other Value Based
Not sure what we do about Care Improvement Plus see from one of our UR departments the behavior below.
Some observations on review of CIP cases.
-       There is no timely response from them about auth/days approved.  We aren’t hearing back from them for days and we are faxing clinicals routinely.  These still don’t have all days approved.  We cannot close cases and send for billing.
-       They are looking at 24 hr notifications.
-       They are asking for MD orders on all ov and IP and that they be signed and certified.
-       They are denying when EHR is approving.
-       They are asking for op reports to confirm procedures and h/p.
-       They are asking to verify the CPT codes on all elective procedures.
-        Too many calls/faxes to UR for additional clinicals when we have already sent.
-       They want a DC summary after DC.
-       On patient acct. 1464800-5144, they gave an auth # then denied.
-   Denials come after the patients are DC’d, unable to do code 44, inform patients and intervene.
-   Statements from Kim that sometimes things don’t get to her b
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