Ask the Experts: Inpatient Versus Outpatient Health Plan Billing

Is it legal to charge an inpatient for outpatient services provided by another facility? When we send an inpatient to another hospital for an outpatient procedure that is not performed at our hospital, and the patient returns to our hospital to complete his/her stay, I have always billed the charges from the other facility (usually as late charges) to the payer. Are there any guidelines that covers this?

Answer 1: There are Medicare guidelines for including outpatient services on an inpatient bill when done by another facility. For example, if the patient needs an MRI while an inpatient and the hospital either doesn’t have one or it is not functioning, the hospital can transfer the patient to another facility for the service and that hospital would then bill the transferring hospital for the charge. The transferring hospital in turn pays the hospital that performed the test and then the charge is added to the inpatient bill. 

This question was answered by: Suzanne Lestina, FHFMA, CPC, vice president, client innovation, AvadyneHealth, and a member of HFMA’s First Illinois Chapter.

Answer 2: Outpatient procedures performed at a facility must be included in the inpatient bill. The outpatient facility will bill the inpatient facility directly, typically through a contracted arrangement, and those charges are included in the inpatient bill. Typically, we saw this for specialized services that we did not provide, such as dialysis in some of our smaller community hospitals. The challenge is having the outpatient charge to the inpatient facility prior to the inpatient bill being submitted—if the charge wasn’t available, we had to adjust the bill.

This question was answered by: Christine Fontaine, CHFP, CPAM, senior director, revenue cycle optimization, Connance, and a member of HFMA’s Maryland Chapter.

Answer 3: I agree with Christine that outpatient procedures done at another facility should be included in the inpatient bill. It doesn’t happen very often, but we sometimes have to send our inpatient to another nearby hospital for a kind of specialized test we can’t perform. The other facility bills us for the service, but the time lag is such that the process doesn’t work well in terms of getting it on the claim, as Christine says. The very low volume means we haven’t prioritized fixing it.

This question was answered by: Ruth Landé, vice president, patient revenues, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.

Answer 4: It is my understanding that you must add the charges to your inpatient account if your patient requires services at another facility while the patient is an inpatient at your facility. This can be problematic from a timing perspective because you need to add the charge to your account and then pay the other facility. 

Historically, we had contracts with area facilities that addressed the charge, and any discount given. It can delay billing for the inpatient stay as you wait for the charge to be posted to your account. If you are part of a hospital system and the purchased service can be provided at a sister facility, you have more control over the timing of the charge process.

This question was answered by: Brenda Loper, regional director of access services for four Sentara Healthcare hospitals. 

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