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Inpatient Claim Charges for Acute Level of Care denied as Acute Care in Subacute Facility

Acute Care Services in Subacute Facility have been reimbursed at the Acute Care Limit

Account Managers at U.S. Advisors, typically examine each copy of “Explanation of Benefits” (EOB) to verify accuracy of adjudication and reimbursement amounts. A specific Reinsurer goes by “level of care” vs. “facility or place of care”. Therefore, allowing charges at non-acute facilities to be reimbursed at the normal acute hospital limit if services delivered are of an acute nature. During the 2006 contract year, a claimant incurred $255,900 inpatient charges in a Subacute Specialty Facility. Reinsuer’s claims analyst considered the charges at this facility as subacute and limited to the $500 per day for 111 days. The Account Manager at U.S. Advisors noticed that the Medical Records which substantiate “Level of Care” had not been requested by reinsurer and the level of care needed to be determined.

After further investigation by the U.S. Advisors’ account manager, it was determined that the 111 days were an acute level confinement. After reinsurer reprocessed the claim an additional $141,930 was recovered for the client.

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