January 4, 2018 - Updated May 7, 2018
Affected claims are being adjusted. Refer to the J15 Part A Claims Processing Issues Log for Updates.
Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities
In a recent report, the Office of the Inspector General (OIG) determined that Medicare inappropriately paid acute-care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities, including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. As a result, beneficiaries were unnecessarily charged outpatient deductibles and coinsurance payments.
All items and non-physician services provided during a Medicare Part A inpatient stay must be provided directly by the inpatient hospital or under arrangements with the inpatient hospital and another provider. Use the following resources to bill correctly:
- MLN Matters® Special Edition Article SE17033 – Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities
- OIG Report: Medicare Inappropriately Paid Acute-Care Hospitals for Outpatient Services They Provided To Beneficiaries Who Were Inpatients of Other Facilities
- Medicare Claims Processing Manual, Chapter 3, Section 10.4
- Provider Compliance Tips for Ordering Hospital Outpatient Services Fact Sheet
- Acute Care Hospital Inpatient Prospective Payment System Fact Sheet; see payment information on page 3
- Items and Services Not Covered Under Medicare Booklet, Page 12