Home Health & Hospice Week

If you fail to check each and every PEP adjustment you see under the imminent recovery project, you might as well sign a blank check to the government.

The Centers for Medicare & Medicaid Services soon will recoup funds for partial episode payment (PEP) adjustments the claims processing system failed to make between October 2000 and April 2003. But you might save yourself $1,300 per claim if you can prove the PEP wasn't warranted.

"There is no way of knowing whether the system recoupment will work correctly," warns M. Aaron Little, consultant with BKD in Springfield, MO. "We would advise that providers verify that any PEPs received through the recoupment process are appropriate."

Little offers these steps for determining the validity of those PEPs:

1. Check for overlapping episodes. Check the common working file through HIQH to find out if a patient was admitted to another home health agency within the same 60-day episode for which you admitted her. The HIQH search allows access to the date of the overlapping episode and the provider number that billed the overlapping episode.

Some HHAs that originally thought they received incorrect PEPs from intermediary Associated Hospital Service of Maine found out they weren't utilizing the HIQH system correctly, notes Bob Wardwell with the Visiting Nurse Associations of America. Make sure you're familiar enough with the system to be able to pull up all HIQH information for patients, even going back two-and-a-half years if the episode in dispute occurred that long ago.

2. Obtain contact information. If an overlapping episode shows up, call your Medicare intermediary to find out the name and phone number of the overlapping provider.

3. Contact the overlapping provider. The second HHA merely might have billed its claim with incorrect dates. Call the provider to verify that information.

4. Call on the intermediary. In some cases, the second agency will realize it used the incorrect dates or inappropriately admitted the patient and correct its bill. But in other cases, the overlapping agency may claim it has a right to the patient for those dates, or will just be lax about submitting a correction. In those situations, seek assistance from your Medicare intermediary, Little advises.

However, CMS hasn't issued formal guidelines for resolving these types of disputes. That may mean it takes longer than usual to obtain help from the FI, if you can secure help at all.