Last Modified: 10/10/2018 Location: FL, PR, USVI Business: Part A
Q: Why do I have a negative reimbursement on my claim? The payment was applied to the Part A hospital deductible and/or coinsurance.
A: A negative payment amount may occur in two situations:
1. When a beneficiary is charged the full Medicare deductible during a short inpatient stay and the deductible exceeds the amount Medicare pays; or,
2. When a beneficiary is charged a coinsurance amount during a long stay and the coinsurance amount plus deductible exceeds the amount Medicare pays.
For a relatively low weight diagnosis related group (DRG), the deductible plus coinsurance can exceed the Medicare DRG payment amount. Medicare records the payment as a negative number on the claim and deducts the amount from the provider payment at the time it is sent. The beneficiary does not receive the excess.
The hospital may charge the beneficiary for applicable amounts shown on the remittance advice (RA) under deductible and coinsurance. The deductible is satisfied only by charges for covered services. The Part A Medicare administrator contractor (MAC) deducts the deductible and coinsurance first from the Prospective Payment System (PPS) payment. Where the deductible exceeds the PPS amount, the excess will be applied to a subsequent payment to the hospital.
Part A hospital stay deductible applied
Reminder: The inpatient deductible for Part A is met per benefit period. The patient begins a new benefit period when he or she has not been in an inpatient facility for 60 consecutive days. If the patient is readmitted to a facility within 60 days of a discharge, he or she is considered to be under the same benefit period or spell of illness and a new deductible does not apply.
Source: Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) 100-04, Chapter 3, Section 40.2.2
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