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.

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