DMAS Reports Medicaid Billing Concern

The Department of Medical Assistance Services (DMAS) reports that it is experiencing an increase in complaints related to hospitals not being able to receive payment for services rendered due to some nursing facilities failure to adjust the admission date on their claims when a resident returns from the hospital. When nursing facilities leave the original admission date on submitted claims, it causes an edit to set within the DMAS claims processing system and the hospital is not paid.  This issue can create large outstanding balances for hospitals.

DMAS has previously issued guidance on this topic in the Nursing Facility Manual, Chapter VI, page 5 and reads as follows:

“NOTE: Edit 0919 - Inpatient Hospital versus Nursing Facility (NF) is being captured due an incorrect admission date for the NF claim being submitted. If a NF has received payment for a hospitalized recipient where the NF did not adjust the admission date to reflect a new admission date upon return from the hospital, the NF claim(s) must be voided by the NF and resubmitted with the correct re-admission date for all claims submitted incorrectly. Updating the admission date on the claim does not have any effect on the PIRS admission process, nor does it require the submission of a new PIRS form to change an admission date.”

Should nursing facilities fail to correct their claims for this issue, then the only alternative that DMAS has is to void nursing facility claims in order to pay the hospital claims. DMAS is working to avoid this action and has asked VHCA to pass this communication along to our members. DMAS has also communicated the concern via GoFileRoom.  Members with questions should contact Melissa Fritzman, Program Administration Supervisor in the DMAS Long-Term Care Division at 804.225.4206 or melissa.fritzman@dmas.virginia.gov.