Medicare Advantage Shadow Billing


Background

The Centers for Medicare and Medicaid Services (CMS) require hospitals to submit claims for traditional Medicare enrollees receiving inpatient services, as well as to Medicare Advantage (MA) plans for inpatient services provided to Medicare beneficiaries who are enrolled in a MA plan. In addition, Inpatient PPS hospitals, Inpatient Rehab Facilities, and Long Term Care Hospitals are required to submit an additional claim for MA beneficiaries, referred to as a “shadow bill.” These informational claims are used by CMS to track inpatient days. The key Medicare reimbursement calculations affected by these MA inpatient days are IME, GME and DSH (through the SSI %).

Challenges

Limited resources are always a concern for Providers because they are being asked to do more with less. Shadow billing creates an additional step in the billing process by requiring Providers to submit a separate bill to Medicare for MA patients. MA patients typically don’t have their Medicare Part A Red, White, and Blue cards with them at registration, so missing information (e.g., Medicare HIC number) restricts the Provider’s ability to submit a shadow bill. Obtaining this information after the fact can prove to be challenging and time consuming.

Our Solution

RSG Inc. has partnered with IMA Consulting to provide MA Shadow Billing Services to our clients.  IMA has developed a proprietary software and methodology, which allows Providers to address the following missed Shadow Billing opportunities:

  • Provider failed to submit an “information only” bill for Medicare Advantage patients
  • Provider is missing key information, which we will obtain as part of this service, for Medicare Advantage patients
  • Patients were misclassified as another financial class but are actually Medicare Advantage
  • Workers Comp and Auto Accident patients are also Medicare Advantage, yet Provider did not submit an “information only” bill