Medicare Part A Claims Payment Delays

We’ve recently been informed of a possible (probable?) delay in claims processing and payments under the new Patient-Driven Payment Model (PDPM) reimbursement model. Our understanding at present is that Medicare Administrative Contractors (MACs) across the country are reporting issues correctly processing Medicare Part A claims. In some instances, all claims submitted after October 1 are being placed on hold pending further instructions from CMS on processing.

Based on a recent PDPM update from the American Health Care Association (AHCA), MACs are also having difficulty processing claims with more than one Health Insurance Prospective Payment System (HIPPS) code. PDPM claims will have multiple HIPPS codes if an Interim Payment Assessment (IPA) has been conducted. While some MACs have been able to process claims with a single HIPPS code, none of the MACs are able to process claims with multiple HIPPS codes.

Many providers bill Medicare (for all Part A stays) at the end of the month or the beginning of a month for the preceding month. This means a large number of October claims are anticipated to be submitted in early November. If the MACs are flooded in November with claims they can’t pay accurately and must research and, at the same time, receive requests for Advanced Payments (see below), their ability to pay maybe be even further slowed due to the volume. This would greatly exacerbate delays.

If you wait until November and the MACs can’t pay, you’re looking at the very end of November or early December for Part A payments. This would mean at least 30-45 day delays in payment. Most providers cannot absorb delays of that length and magnitude.

As mentioned above, if you experience a delay in payments or believe you will experience financial hardship due to the delay in payments, we strongly advise that you complete a Request for Advanced Payments under Part A. If you would like to view the rules regarding the filing of a request and a sample request, they are located on our website at Medicare Request for Accelerated Payments-Part A. The request for advanced payments should be made with the Department of Debt Recovery of your MAC.

For more information, contact your MSL representative who will be happy to assist your organization. Please contact us at 1-800- 683-5401.