Timely Billing Requirements: Medicare Part C Claims

Possibly in the wake of the United States Court of Appeals decision in Loma Linda University Medical Center v. Kathleen Sebelius, Case No. 10-5116, CMS published a clarification of their timely billing requirements regarding “shadow billing” Medicare Part C claims. The Provider prevailed in their appeal of not having timely billed. The Court concluded that the Medical Center did not receive notice “with ‘ascertainable certainty,’ of the billing deadline for seeking payment for medical education costs associated with Medicare+Choice (Part C) inpatient days.”

In the FFY 2013 PPS Proposed Rules, published in the May 11, 2012 Federal Register (page 27973), CMS “clarified” that the Medicare Part A billing statutes applied to billing no-pay Part C claims. Using the language “it was always our intent” and “we are clarifying again” and “we are clarifying once again” CMS might be attempting to ignore the ruling of ascertainable certainty by the US Court of Appeals and once again attempt the feat of closing the barn door after the horse got out.

One could take the position that this published “clarification” is a formal notice that the Part A billing statutes will be applied to Part C no-pay claims. As such, one could also construe that they may have a year from the May 11, 2012 notice to catch up the previously unbilled M+C claims.


Identify and attempt to bill hard copy M+C claims for any cost report years that have not been finalized and for cost reports where you have appeal rights on unbilled M+C claims. Most likely, the claims will be rejected due to the Part A billing statutes; however, this action will be the basis to document the claims and payments for the appeals.

Amend cost reports that have not been audited to add this issue as a protested amount if it is not already identified as an issue.

Catch up on all billing prior to May 11, 2013 and save copies of the bills submitted and correspondence between the hospital and the MAC to show they were presented within one year of the “notice” date.

PFC can help with any and all stages of this process. If you have any questions, please e-mail Joseph Fass (jfass@pricefass.com) or Susan Starr (sstarr@pricefasss.com) to discuss further.

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