Billing for In-Custody Patients, Malnutrition Definitions, and Refunds for CHAMPVA Care: A News Hodgepodge

Today I have a few newsworthy items for you.

First, Medicare updated one of the Manuals with information on billing for patients who are in the custody of a penal authority. You can find that in the Medicare Benefit Policy Manual, Chapter 16, section 40.7. But from my review, there is really nothing new, suggesting that the Centers for Medicare & Medicaid Services (CMS) is simply putting into the Manual what has been established policy.

As a reminder, payment for care rendered to patients who are considered “in custody” is the responsibility of the incarcerating agency. And this actually falls into a broader category of Medicare payment exclusions that is outlined in 42 CFR § 411.4, which prohibits Medicare payment when neither the individual beneficiary nor any other person or organization (by reason of such individual’s membership in a prepayment plan/insurance or otherwise) has a legal obligation to pay for the item or service.

That means that unless the jail or prison charges all patients for medical care, Medicare will not pay for care provided to those patients who have Medicare coverage.

But most importantly, this is a chance for me to remind you that the term “in custody” in this regulation also refers to escaped prisoners. So if an escaped prisoner presents to your hospital for care and is a Medicare beneficiary, you are obligated to find out from where they escaped and bill that entity for the medical care (and not Medicare).

Moving on, as some of you know, I am allergic to clinical documentation integrity (CDI); just talking about it gives me hives. But I have once again premedicated to be able to share a brief update. The diagnosis of malnutrition is one that payers love to remove from claims in order to pay the hospital less.

And two weeks ago, the New England Journal of Medicine published a review article on malnutrition in older adults. This article referred to Global Leadership Initiative on Malnutrition (GLIM) criteria without a mention of American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. This means that payers will latch onto this authoritative journal and demand patients meet those criteria to validate the diagnosis.

You can certainly fight for the right to use ASPEN, but CDI teams should be certain to review the GLIM criteria and anticipate the possibility of increased denials.

Finally, it appears that the U.S. Department of Veterans Affairs (VA) inappropriately paid some claims under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) for patients who had other insurance as far back as 2021, and they are going to demand refunds. But after you refund the payment, via an online portal, they say you can bill the primary insurance, and if that claim is rejected, you can then resubmit the claim for payment.

Now, I would love to know if they really think any insurer is going to pay a claim that is submitted more than one year after the date of service. We all know every such claim will be rejected, and then the provider must go through the resubmission process, only to get the payment they just refunded. Talk about government inefficiency; how hard would it be to put an edit only asking for repayment for claims within the last year?