Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities

Generally, Medicare should not pay an acute-care hospital for services (for example, outpatient
surgery or lab work) furnished to a beneficiary at that facility when the beneficiary is still an
inpatient of another facility. Acute-care hospitals, under arrangements with the LTCH, IRF, IPF,
and/or CAH, should look to the LTCH, IRF, IPF, and/or CAH for payment for the outpatient
services it provides to the beneficiary while an inpatient of that other facility. Additionally, acute
care hospitals should not charge beneficiaries for outpatient deductibles and coinsurance
payments as a result of such services.
Medicare system edits examine claims history for the presence of a covered Part A inpatient
stay when also processing an outpatient claim for a date of service when the beneficiary was an
inpatient. If Medicare paid for an inpatient stay for the same date of service as the incoming
outpatient claim, Medicare edits will appropriately deny payment for the outpatient services.
There are occasions when Medicare may get an outpatient claim before getting an inpatient
claim. In these cases, after paying the inpatient claim, the MACs will recover the outpatient payment from the provider and direct the provider to refund to the beneficiary any
inappropriately collected coinsurance and/or deductible for the outpatient services. Hospitals
should review the policies restated in this article to bill correctly in these situations.

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