In the absence of a clearly defined level of care, most payers will only approve of the level of medical care. A patient may need surgical care after admission, but may need a telemetry or intensive care unit during their stay. Scenario 2: Suppliers and payers enter into an agreement that the payer pays a rate of $1500 per day as long as another authorization is obtained. The LOA/SCA does not specify the level of care at which care can be provided. The LOA/SCA should indicate whether care or royalties should be applied. Payers may decide that they do not pay a percentage of the fees charged, because the facility provides higher care than is necessary or some days are not medically necessary. A payer may also charge tape requirements, laboratories and image processing services and indicate that these are bundled fees and are not refundable as CMS does not pay these fees. A supplier should specifically negotiate that the percentage of payment applies to all fees charged without exclusion. Scenario 3: The entity and the payer enter into an agreement to pay a percentage of the fees charged. LOA/SCA statements will be reimbursed at 40% of the charges.
The provision of a higher level of care means that a provider must be compensated at a higher rate than the level of surgical care. Providers, particularly long-term care providers, should negotiate reimbursement for many levels of care. In their other letters of authorization, payers will indicate the level of care they will approve so that the calculations for expected payments are simple and simple. In most cases, hospitals negotiate with the payer to perform an LOA/SCA with a defined reimbursement rate that is acceptable to both the payer and the supplier. Most receivables are negotiated either to pay per day, by pricing plan, or percentage of the total fee charged. It sounds pretty simple; However, LOA/SCA is not a guarantee of payment. There are many cases where claims are underpaid or rejected, although a supplier has registered an LOA/SCA. Below are some scenarios that suppliers often find. In order to expedite the refund, a copy of the LOA/SCA must be submitted with the application. Suppliers should contact the payer`s representative who performed the LOA/CAS in the event of a problem. Agents have limited information, access and understanding of LOA/SCA and, in most cases, maintain the position that the claim was properly paid. Scenario 1: The patient has traditional Medicare as primary and a commercial plan as secondary.
Medicare Part A is sold out before registration. The provider is not with the secondary network. The hospital runs an LOA/SCA with the supplement to pay 1,500.00 USD per diem. The LOA does not mention the reimbursement of Medicare Part B Coinsurance. The supplement is paid daily at $1,500.00 per day, but does not pay The Medicare Part B co-insurance. The LOA/SCA must be clear on his face that Medicare Part A benefits were exhausted prior to authorization and that the payer who performs the LOA/SCA is paramount. Hospitals often enter into agreements with an insurance provider (LOA) and single case agreements (ACSs) when the provider is not considered a network provider with the patient`s insurance plan.