Refund Policy

Specific Policies and Procedures 1. Bill only for items or services actually rendered. a. Never submit a claim for reimbursement without adequate information to indicate that the service billed for was actually rendered. 1) Such information should include the date the service was rendered or the item provided, the identity of the person to whom the service was rendered or the item provided, a description of the service rendered or item provided, and the identity of the person providing the service or item for which reimbursement is sought. 2. Bill only for medically necessary services. a. Claims should only be submitted for services that the Corporation has reason to believe are medically necessary and that were ordered by a physician or other appropriately licensed provider. 1) Reimbursement under Medicare for any such services must be “reasonable and necessary” according to the standards for Medicare reimbursement set forth in applicable statutes and regulations. a) Should any question arise regarding the “medical necessity” of a service, adequate documentation to prove the medical necessity of the service must be provided and reviewed prior to submitting any claim for reimbursement or assigned ABN. 3. Double-check all billing codes. a. Claims should only be submitted when the correct billing code has been assigned to the item or service as intended by the payer (including Medicare and Medicaid). 1) Should any questions arise regarding the proper code to be assigned to an item or service, resolution of the issue should be obtained from appropriate management personnel (with the advice from legal counsel or other consultants, as needed), the Intermediary, or payer prior to any claim submission. 4. Do not routinely waive any copayment or deductible. a. Claims may not be submitted if the patient has not been charged with the appropriate copayment or deductible, unless the patient to whom the item was provided or service was rendered is determined to be indigent. 5. Ensure that all claims have been properly bundled. a. Make sure that all claims are bundled and that global billing codes are properly assigned prior to the submission of claims. 1) Check all claims to make sure that there is no duplication of codes for multiple portions of the same service (i.e., removal of multiple lesions or tumors). Administrative Policy # 6015.00 Page 5 of 8 6. Scrutinize carefully all cost reports. a. Verify that all information contained in cost reports is accurate, ensuring specifically that: 1) Costs are not claimed unless based on appropriate and accurate documentation. 2) Allocations of costs to various cost centers are accurately made and supportable by verifiable and auditable data. 3) Unallowable costs to various cost centers are accurately made and supportable by verifiable and auditable data. 4) Accounts containing both allowable and unallowable costs are analyzed to determine the unallowable amount that should not be claimed for reimbursement. 5) Costs are properly classified. 6) Adjustments are made to account for the results of the Intermediary’s prior year audit and a) Are not claimed for reimbursement or b) Are claimed for reimbursement but are clearly identified as “protested,” if applicable, on the cost report. 7) Procedures are in place and documented for notifying promptly the Intermediary or other applicable payer of errors discovered after the submission of the Corporation’s cost reports. 7. Ensure that claims are submitted only for services provided by the Corporation or “under arrangements” with other suppliers/providers. 8. Ensure that no duplicate billing occurs. a. Check all claims to make sure that no more than one claim is submitted for the service for which reimbursement is sought. 9. Refund credit balances accurately. a. Remove credit balance accounts from active accounts and place them in a holding account until reimbursement claim is processed to the appropriate payer program. 10. Do not submit claims for improperly referred patients. a. If the Corporation becomes aware of any contracts or arrangements which might violate the Antikickback Statute, Stark Law, or other anti-referral law, the Billing Department should be advised immediately. 1) Patients who may have received services due to an improper referral arrangement should be identified and no claims for reimbursement from Medicare or Medicaid should be sought for the treatment of such patients. 2) See also the Policies regarding Physician Issues, Payments and Discounts, and Tax Exempt Status for information regarding compliance with the Antikickback Statute and Stark Law. 11. Review of current formal billing policies and procedures. a. Review the current “formal” billing manual and policies for compliance with all billing requirements and revise as appropriate and necessary. Administrative Policy # 6015.00 Page 6 of 8 12. Review of current informal billing policies and procedures. a. Review “informal” billing practices for compliance with all proper billing requirements (i.e., what to do when the computer will not accept when the processor enters what he or she believes to be the appropriate code), and revised as necessary and appropriate. 13. Refund all credit balances. a. Refund all credit balances in a timely and appropriate manner.