October 2019

We’re resuming Medicare Plus Blue PPO place-of-service audits

Blue Cross Blue Shield of Michigan is resuming inpatient place-of-service audits for all Medicare Plus Blue^SM claims.

Beginning with service dates on or after Sept. 1, 2019, we won’t reimburse for inpatient hospitalizations where the medical record doesn’t support the inpatient setting that was billed. Denials will be based on whether the patient’s level of hospital care was billed correctly, not on medical necessity. Providers can avoid possible recovery of funds during claims processing and post-payment audits by closely following rules for documentation, coding and billing set by the Centers for Medicare & Medicaid Services and Blue Cross.

Hospitals are liable for the denied claims and aren’t allowed to charge or balance bill Medicare Advantage members. However, they can rebill Medicare Part B services.

Process

HMS^® will perform Medicare Plus Blue place-of-service audits on behalf of Blue Cross. Hospitals must submit medical records to HMS for audit, upon request. If the inpatient care is documented in the medical record, the hospital will receive a no-findings letter. If HMS finds the inpatient level of care isn’t supported in the medical record, hospitals will receive case summaries that include the rationale used in determining the denial. To appeal the decision, hospitals must follow the appeals process described in the Medicare Plus Blue PPO manual.

If you have questions during an audit, call 1-866-875-1749 to talk with an HMS representative.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.