Don’t Miss a Medicare HMO Shadow Bill Claim

Employee time clocks were invented to protect both employers and staff. They’re records of the hours worked, and protect business owners by making sure employees worked the hours they claim. Employees are protected, too, because they have a record of their time and their employer must pay them for that time.

Medical claims function the same way. In Medicare cost reports, they’re the time punch card. Claims are filed with insurance to get paid for services. And there’s a certain claim that often gets overlooked—the Medicare HMO “Shadow Bill” claim.

Shadow billing, also known as “no pay” or “information only” claims, is an unofficial term that refers to the process that hospitals should follow when providing inpatient services to Medicare Advantage/HMO patients. The claims should be submitted to their Medicare Administrative Contractor (MAC) so they can get credit for the patient days of service, just like employees punch a time clock to record time spent working.

The patient days can then be used in calculation of reimbursement for HIT, Medical Education, Allied Health, Disproportionate Share or Uncompensated Care. The PS&R report 118 summarizes the Medicare HMO days.

Tip #15:

If your hospital’s internal report has Medicare HMO days, you should expect to have PS&R report 118.

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Medicare Advantage HMO Claims

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.

Avoid Fraud: Use Worksheet G

Stethoscope, handcuffs and money on gray background

It seems every time you watch the news or read a paper, there is something about health care fraud. In 2014, the federal government recovered nearly $5.7 billion in health care fraud cases, an increase of $1.9 billion from 2013. Health care fraud can take many forms, most commonly it involves the submission of improper claims. But there also the risk of financial fraud by overstating revenues or expenses. One way CMS tries to prevent this is to require the cost report be completed using data that is “current, accurate and . . . capable of being audited.” The worksheet series “G” includes a balance sheet and income statement and CMS indicates these should be consist with financial statements.

Tip #14:

Ensure Worksheet G amounts can be reconciled to Financial Statements (Pub. 15-2, §Section 4040).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-2

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.