Rena
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Chair, American Association of Nurse Assessment Coordinators
[EMAIL PROTECTED]
Subj: RE: FW: Medicare verses HMO
Date: 2/26/04 11:16:03 AM Pacific Standard Time
From: [EMAIL PROTECTED]
Reply-to: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Sent from the Internet
I did look at the RAI Manual reference you cite. It is clearer about the
consequences for the time the PPS is done than it is for the time when it is
transmitted. Perhaps someone else can clarify what the consequences of late
transmission would be.
Is the HMO denying because the resident was no longer a member of that HMO
at the time of service? Sometimes this is the case, but they precertify
anyway by mistake. They still won't pay for the stay.
>From: "Richardson, Christine" <[EMAIL PROTECTED]>
>Reply-To: [EMAIL PROTECTED]
>To: <[EMAIL PROTECTED]>
>Subject: RE: FW: Medicare verses HMO
>Date: Thu, 26 Feb 2004 12:40:58 -0600
>
>This HMO was in place of Medicare. We had precertified her before she came
>in but the HMO still is denying.
> Since the assessment was done in the time frame I wont get a default rate
>will I? I thought you only got a default rate if the assessment was
>completed late, not with in the time frames of Medicare, not if it was
>transmitted late. This is info from BKD and Benedictine Health.
>See page 2-40 in RAI
>Second paragraph states "If a late/missed assessment has a ARD with in the
>allowable grace period, no financial penalty is assess.
>
>I do think its good advise to send a assessment on every one, requradless
>if
>HMO or not.
>
>Thank you sooo much for your input on this!
>Christine
>-----Original Message-----
>From: Anne Burrows [mailto:[EMAIL PROTECTED]
>Sent: Thursday, February 26, 2004 12:24 PM
>To: [EMAIL PROTECTED]
>Subject: RE: FW: Medicare verses HMO
>
>
>
>If I understand you correctly, you expected that an HMO would be the payor,
>but they say Medicare is primary. I don't know whether this person had
>two
>
>insurers (HMO and Medicare) or one (member of a Medicare HMO).
>
>If the person has insurance through a job, and also has Medicare, either
>one
>
>could be primary depending on the circumstances. The Medicare manual
>gives
>
>specifics. When there is doubt about which one is primary, the safest
>thing
>
>to do is to do the PPS assessments just in case. They should be
>transmitted
>
>before the deadline for transmission, or else you can bill only at the
>default rate if it turns out that Medicare is primary.
>
>You are in a similar situation when you believe that a person is a member
>of
>
>a Medicare HMO and you plan to bill the HMO. But you find out later on
>that
>
>he or she disenrolled from the HMO and went back to traditional Medicare.
>It is a good idea to do and transmit PPS assessments for members of
>Medicare
>
>HMOs to avoid getting caught without having done them when you find out
>about a disenrollment. Again, if the deadline for doing and/or
>transmitting
>
>has passed, you can bill only at the default rate.
>
>In your situation, you are well past the deadline for transmitting. The
>resident was with you in November, and the deadline for transmitting is 31
>days after the completion date. Transmitting it now wouldn't help. You
>are
>
>still limited to billing at the default rate, whether you would transmit it
>or not.
>
>You also asked about changing the coding from insurance to Medicare. That
>would be appropriate if you were still within the window for transmitting.
>If there is an error and we haven't transmitted yet, we should correct the
>error first.
>
>>From: "Richardson, Christine" <[EMAIL PROTECTED]>
>>Reply-To: [EMAIL PROTECTED]
>>To: <[EMAIL PROTECTED]>
>>Subject: FW: Medicare verses HMO
>>Date: Thu, 26 Feb 2004 11:00:20 -0600
>>
>>
>> Second try.
>>> -----Original Message-----
>>>From: Richardson, Christine
>>>Sent: Thursday, February 26, 2004 7:59 AM
>>>To: '[EMAIL PROTECTED]'
>>>Subject: Medicare verses HMO
>>>
>>>
>>>
>>> Hope some one might have had this problem.
>>>
>>>Problem: Res admitted in November under HMO.ARD set at day 5 but was
>not
>>>transmitted d/t res discharged prior to initial assessment.
>>>Now HMO denying claim, says Medicare is primary. The assessment was
>>>completed in the correct time frame but wasn't transmitted. It is
>coded
>>>for Insurance and no Medicare.
>>>
>>>Should I leave it the way it is? Change the codes to reflect Medicare
>>>need?
>>>Do I call some one since it will be transmitted late?
>>>
>>>I really, really need help!
>>>
>>>Thanks in advance
>>>Christine Richardson LPN/CRNAC
>>>Nursing Assessment Coordinator
>>>
>>
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>>
>>
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>>The Case Mix Discussion Group is a free service of the
>> American Association of Nurse Assessment Coordinators
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>/----------------------------------------------------------
>The Case Mix Discussion Group is a free service of the
> American Association of Nurse Assessment Coordinators
> "Committed to the Assessment Professional"
>Be sure to visit the AANAC website. Accurate answers to your
> questions posted to NAC News and FAQs.
> For more info visit us at http://www.aanac.org
>-----------------------------------------------------------/
>
>NOTE: This e-mail message may contain information that is privileged,
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>forward or use
>this information in any way. Delete it immediately and contact the sender
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>as possible by the reply option or by telephone at the telephone number
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>available). In the event you cannot fulfill your obligation or there has
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