Office of the Inspector General (OIG) Post-Acute Care Transfer (PACT) Policy Audit Questions and Answers

Summary
The Office of the Inspector General (OIG) initiated another audit involving claims billed with an improper patient status code for the Post-Acute Care Transfer (PACT) Policy by Medicare Administrative Contractors (MACs).

Palmetto GBA and state hospital associations have received inquiries related to the notification letter requesting full refunds of improperly paid PACT claims within 40 days, unless hospitals request a redetermination or send an adjusted claim. The initial adjustments are not yet processed as final, only the letters and timeframes were sent to hospitals.

Resources

• OIG Audit Report: Medicare Improperly Paid Acute-Care Hospitals $54.4 Million for Inpatient Claims Subject to the Post-Acute-Care Transfer Policy
• "OIG Audit Adjustments" article on the Palmetto GBA website

Q&A

Questions
I am writing to obtain the process for the adjustments to the PACT claims where the patient later received care. I am requesting assistance.

• What is the reprocess of the claims with a request for full reimbursement in order to receive the per diem reimbursement?
• Will timely filing be an issue for correcting the claims being adjusted?
• Do all claims billed incorrectly require redetermination or only the claims the provider believes billed correctly with documentation?

Responses
The overpayment is due for the amount noted on the demand letter. If not repaid in 40 days, offset will begin on the overpayment, unless an appeal redetermination request has been submitted. The provider can submit an adjustment claim and will be reimbursed the per diem amount once the reprocessed claim finalizes and pays.

Our Claims and Finance staff has implemented processes to address the adjustment due to OIG Audit A-09-19-03007. The Claims Payment Issues Log (CPIL) alert entitled OIG Audit Adjustments was updated Monday, February 3, 2020, and provides further instructions for providers.

Providers can submit adjustment claims with the appropriate patient discharge status code to receive a per diem payment. For claims that have passed timeliness, please include the comment “Adjustment due to OIG Audit A-09-19-03007” in the remarks section in order to bypass timeliness. This adjustment should be sent as soon as possible in order to receive reimbursement at the per diem rate. The DRG overpayment will still be collected.

If the provider wishes to dispute the overpayment decision and stop the recoupment process, they may submit a redetermination request. If the provider does not wish to correct or dispute the decision, then the withholding is initiated on the 40th day from the date on the demand letter.