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Clarification of swing-bed hospital services reimbursement

In December of 2015 the Division of Medicaid (DOM) transitioned inpatient hospital services from regular fee-for-service to its managed care program, MississippiCAN. Despite originally being included in that transition, DOM has determined that swing-bed hospital services should be separate from inpatient services and not fall under managed care. As such, DOM maintains responsibility for the authorization and reimbursement of swing-bed services delivered to both regular Medicaid beneficiaries and MississippiCAN members.

Swing-bed services are extended-care services provided in a hospital bed that has been designated as such and consists of one or more of the following:

  • Skilled nursing care and related services for patients requiring medical or nursing care.
  • Rehabilitation services for persons who are injured, disabled or sick; and/or
  • On a regular basis, health-related care and services to individuals who, because of their medical status, require care and services above the level of room and board, which can be made available to them only through institutional facilities.

DOM provides payment for routine nursing facility services furnished by a swing-bed hospital in accordance with the State Plan.

Because of the decision regarding inpatient services, the Coordinated Care Organizations (CCOs) contracting with MississippiCAN should proceed as follows:

  • The CCOs should recoup payments incorrectly made to providers for swing-bed hospital services for such services rendered on or after Dec. 1, 2015.
  • The CCOs should notify providers to contact the DOM Utilization Management/Quality Improvement Organization (UM/QIO) vendor, eQHealthSolutions, for authorization.
  • The CCOs should notify providers to submit swing-bed claims to DOM’s fiscal agent to process payments of all payments recouped by the CCOs in response to the memorandum of April 21, 2016, and future swing-bed hospital services rendered to MississippiCAN members.
  • The CCOs should deny all swing-bed authorizations and claims submitted to a CCO on or after Dec. 1, 2015.
  • DOM requests immediate provider outreach by the CCOs to educate providers of this policy.