Billing Per Diems on Non-Infused Days
If we have a Monday, Wednesday, Friday antibiotic patient, can we bill a 7-day Per Diem? -- Cynthia Donahue
Response Summary
There were 9 Listserv responses to Cynthia’s question which created considerable discussion. In summary, the responses ranged from bill the antibiotic per diem for all 7 days to you can only bill the antibiotic per diem for the days infused. There was also much discussion regarding contractual language agreed to between the provider and payer.
The NHIA position on Per Diem is:
As related to reimbursement, the term "per diem" represents each day that a given patient is provided access to a prescribed therapy, beginning with the day the therapy is initiated and ending with the day the therapy is permanently discontinued. The term "permanently" shall not be construed to infer that a therapy shall never again be initiated, but rather that continuation of the therapy is simply not predicted or anticipated at the time of cessation. The expected course and duration of the treatment shall be determined by the plan of care as prescribed by the ordering physician.
It shall not be necessary for the patient to receive an actual drug infusion each and every day in order to be considered covered under an existing per diem, so long as additional infusions are anticipated in the near future as prescribed in the physician plan of care. The fact that the health care provider anticipates continued responsibility for the patient and incurs costs related to such responsibilities, remains accountable for the provision of such anticipated care, and is responsible for the acquisition and allocation of resources that will be necessary to meet these obligations, shall deem the existing per diem to be current, valid, and in force.
This definition is valid for per diem therapies of duration of up to and including every 72 hours. Therapies provided beyond this range (weekly, monthly, etc.) fall outside of the per diem structure, and should have separate reimbursement rates that are specified on a contractual or other basis.
Rock-Pond Analysis
We would like to thank the following Listserv participants for their contribution, insights and opinions on this subject: Matt Smith, Patricia Henriques, David Franklin, Barbara Robinson, Steve Magliacane, Lynette McFarland, Lori Duvall, Barry Stenberg and Connie Maranville.
At issue is whether industry standards of practice and contractual language collide. David Franklin stated it the best, “The critical word there is "contract." If you have signed a document agreeing to accept those terms, then you are bound by it. The counter measure would be to decline to sign such a contract... “.
NHIA assists and supports our industry in defining standards of practice but as providers operating businesses we must be prudent in understanding contractual obligations we have committed to. If you as a provider have a contractual obligation you are not satisfied with, then you must negotiate directly with that payer to educate and seek to amend, otherwise you are only harming your own business.