HOSPICE CLAIMS SUBMITTED DIRECTLY TO MCR INCORRECTLY

DESCRIPTION OF THE ISSUE

Previously we had billed Hospice covered patient claims to Medicare with GW modifier to get quicker payments. Balance of 20% coinsurance was billed towards patients. Client raised an issue to file the claims to the concerned Hospice care itself instead of billing Medicare.

CONCEPT

Whenever we find patients with Hospice coverage for a particular service date, we must check with Hospice whether the patient was in Hospice for the specific DOS, if yes we must bill that concerned Hospice care and not Medicare, if not we could bill Medicare with GW modifier (which indicates the claim not related to Hospice).

Per Client - Incorrect filing of all claims towards MCR directly will cause a red flag for our provider in MCR system.

SOLUTION

On finding patients under Hospice coverage, we need to place a verification call towards Hospice care to inquire whether the patient was/is in Hospice for the specific DOS.

If incorrectly paid Hospice claim towards Medicare with GW would be refunded and the claims would be forwarded towards the concerned Hospice care, before that we need to confirm whether the GW modifier is removed from the claim