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Tricare Philippines Newsletter 12011
How to File a Claim for the Hospital Portion of a Hospitalization
Most inpatient claims consist of a hospital bill that consists of charges for a room and charges such things as operating room, laboratory, Radiology, disposable items and others and bills for professional fees from various physicians that treated, evaluated or provided another service such as anesthesia to you while you were a patient in the hospital. The physician’s billings are referred to as professional fees. Many times the professional fee charges will be added as the last entry on the hospital bill and paid directly to the facility. In some cases while they are added to the hospital bill the physicians will be paid separately. In some other instances the professional fees will not appear on the hospital bill but be separately billed by each physician. Depending on the hospital some items such as medical supplies and pharmaceuticals may have to be purchased outside the hospital. If this happens these are considered part of the hospital bill.
Due to the complexity of filing inpatient professional fees they will be addressed in one or more separate newsletters.
See TRICARE Philippines Newsletter 12005, Basic Claim Filing Rules for the Philippines for the basic considerations when filing a claim. (All previous newsletters can be accessed by going to the Archive).
Double Proof of Payment
The most common time when Double Proof of Payment is required is for hospital claims. So be aware of that possibility and insure you have the documents you need. See TRICARE Philippines Newsletter 12010, The Double Proof of Payment Issue.
Documents Required for both the Hospital Portion of the Claim and the Professional Fees.
When someone is hospitalized as a minimum there will be an itemized bill for the hospital portion of the care and one physician. As mentioned, for the physician or physicians involved their fees are generally referred to as inpatient professional fees also known in the industry as Pro Fees. Some hospitals, depending on your arrangement with them, will require an initial deposit and periodic payments to replenish the deposit as the original one is used up. Some will require cash payments for pharmaceuticals and lab procedures. In these cases you will have multiple receipts for the hospital including the final receipt paid at time of discharge; all of these will be needed when filing the claim.
If the professional fees are paid separately to the physicians, these receipts will also be needed for the professional fees claim. In some instances, particularly in the provinces and smaller hospitals, some items may have to be purchased outside the hospital for the patient’s treatment. Most often these include pharmaceuticals and disposable medical supplies. On rare occasions durable medical equipment may be purchased outside the hospital as well. When this happens it is important to retain all prescription documents and receipts as these will be needed when filing the claim. It is also important to try to use certified providers for these whenever possible. Not using certified providers for these services will hold up the entire hospital portion of the claim until they are certified which can take up to 90 days or more. See “What can we do to help insure a provider is certified and we get paid?” in the TRICARE Philippines Newsletter 12008, Current Understanding of the Provider Certification Process.
Finally your primary physician should prepare what is called a Discharge or Narrative Summary. A copy of this document is not an absolute requirement but a very good idea to have to assist in preparing the professional fees claim. If you had surgery you will need a copy of the operation report (OR) as well to assist in preparing this portion of the claim. If you had surgery you will also need to know the time when you were transported from the recovery room to your hospital room. This is needed to calculate the time of service for anesthesia for the Anesthesiologist’s bill for the professional fees claim.
Recap of documents resulting from a hospitalization
- Itemized hospital bill
- Receipt(s) for the hospital charges
- Bill(s) from the physician(s)*
- Receipt(s) for the physician charge(s)*
- Prescription documents and receipts for items obtained outside the hospital
- Discharge Summary*
- OR report if surgery was performed*
- The time you left the recovery room going to your hospital room*
* Retain for professional fee portion of the claim.
Include Professional Fees or not when Filing for the Hospital Charges?
Until recently if the professional fees were included on the hospital bill and or receipt you had no choice because the TRICARE Management Activity (TMA) and Wisconsin Physicians Service (WPS) would automatically break out your submission into two claims; one for the hospital bill and another for the professional fees. If you were not ready to file the professional fees because you weren’t able to properly break out each individual procedure and then medically code them so you could allocate the appropriate portion of the global bill to each procedure and do this for each physician, you would find that portion of your claim for professional fees denied for non-receipt of requested information.[i] Our review of claims data for beneficiary filed claims for inpatient professional fees showed that, by count, 63% were denied for payment and mostly for “Requested Information Not Received”. Even of the claims that were approved for payment 45% of the billed amount was disallowed, in our opinion probably because the patient didn’t understand how to document all the individual procedures that would be needed to maximize their ability to receive proper reimbursement. In total only, when considering the total billed amount of all claims for professional fees, only 6.8% was actually paid to beneficiaries. Our experience when breaking out these claims as TMA and WPS require that most are approved for payment at 100% of the billed amount; the excepting being surgery where the CMAC greatly understates normal local fees by as much as 50%. This clearly showed this as the single biggest area of concern for beneficiaries when filing claims. For those that would like to see the results of the complete study of Philippine TRICARE claims they can access it by clicking the link, Analysis of Philippine TRICARE Claims.
Because the hospital portions of these claims are relatively easy to file and some beneficiaries may need to recoup as much as possible as soon as possible to pay for additional care, we addressed with WPS the possibility of allowing the beneficiary to split the claim and file for only one or the other at a time. Essentially in the same manner a hospital would file a claim for only their portion of the bill while the physicians filed their own claims as is routinely done in the U.S. WPS agreed this is a good idea and while they haven’t gotten final approval from TMA, they agreed to provide an interim process that we could disseminate to allow beneficiaries to do the same thing.
If you desire to file the hospital portion of the claim only, then do the following when filling the claim for the hospital charges.
- If the physician bills were not included with the hospital bill then simply don’t include the individual physician bills or receipts.
- If they are included take the copy you intend to mail or fax, don’t do this to the original, and draw a single line through each of the professional fee charges that are not included as part of the hospital charges. The line should be clearly visible but not so wide that someone can’t read what was there. (Professional fees shown on the bill for reading lab and x-ray results by hospital employed physicians are part of the hospital bill and should not be lined out.)
- Include in all capitals at the top of your narrative that the claims is being submitted for hospital charges only with reference as shown below.
Preparing the Documents for Filing the Claim
Insure you have a clear and readable copy of the hospital itemized bill which should list all individual charges with a summary and total on the last page. Gather all your receipts in date order that document all your hospital payments from initial deposit, periodic or partial payments to final payment. If you purchased items outside the hospital at the request of the hospital or doctor gather the orders and receipts and place them in order, e.g. order followed by receipt. Make legible copies if you intend to mail or fax you claim via local fax. If you intend to email or fax via internet obtain legible scans of the documents; be sure to properly identify each scan so you can find and place them in proper order later.
Follow the guidance in Tricare Philippines Newsletter 12005 - Basic Claim Filing Rules for the Philippines for completing DD Form 2642 and the Narrative.
Additional Narrative Guidance
If you intend to file for only the hospital portion of the claim follow the instructions above and include this comment in capitals and in bold at the top of the narrative “THIS CLAIM IS FILED FOR HOSPITAL CHARGES ONLY, IN ACCORDANCE WITH INSTRUCTIONS FROM MR. PABICH, VICE PRESIDENT, WPS TRICARE OVERSEAS CLAIMS, CLINICAL REVIEW, TRAINING & QUALITY IMPROVEMENT” Then follow the rest of the guidance above for completing the Narrative.
If there is one or more receipts for items purchased outside the hospital, list each one individually with a short description and the amount paid. Then list the total amount of the hospital bill. Be sure to exclude professional fees from the amount. The hospital bill should include a subtotal of only the hospital charges. (If you are filing for both at the same time place the professional fees on separate lines for each physician but include your itemized breakout of the procedures.) Then place a grand total of the amount of the claim which would include the charges for the items purchased outside the hospital, if any.
When Ready to Submit the Claim
Place your documents in the following order and submit.
- DD Form 2642
- Narrative
- Itemized hospital bill
- Receipts for hospital bill in date order
- Outside orders with each order followed by its receipt.
When mailing a claim each document should include the patients name and sponsor’s SSN. If one or both are missing consider printing them on the margins of the document copy you are mailing. This will assist if one or more documents get separated during processing.
If you are sending your claim by secure email or internet fax it is best to consolidate all the individually scanned documents into one document to reduce the chances of loss of one or more at WPS. In my opinion the format of choice is PDF. There are many free programs and internet sites that can convert various other forms of documents such as .jpg, .tiff, .txt, .doc or .docx to PDF and others that can then consolidate all the individual .pdf files into a single .pdf file.
What’s next?
The next, probably two, newsletters will attempt to deal with the complex issues involved in filing for professional fees resulting from hospital stays. Understand those that do this for a living in the U.S. have college degrees in this specific field and attend hundreds of hours of continuing education to maintain their skills. To add to the complexity one has to convert local terms to U.S. standard medical terminology to at least some extent and know what questions to ask their doctor. So, at best, we can only provide the basics to accomplish this. However, for the basic uncomplicated, stay that doesn’t involve surgery what we intend to provide should be sufficient. In the case of surgical cases it will at least provide the ability to obtain a reimbursement greater than the current 6.8% that has historically been paid.
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[i] When WPS determines some information is missing they send a letter requesting the information. If it is not received within the stated 90 days the claim is denied due to non-receipt of the information.
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