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Home Health & Hospice Week

Billing:

Check PEPs Before RHHIs

Published on Tue Jul 22, 2003

Regional home health intermediaries will give you a one-week grace period to figure out if your partial episode payment adjustments are valid - then they'll be dipping into your pockets.

Home health agencies that fail to take advantage of the opportunity may find it much harder to get PEP money back from Medicare instead of preventing them from taking it in the first place, points out consultant Melinda Gaboury with Nashville-based Healthcare Provider Solutions.

The recoupment process will include:

  • Adjustments. RHHIs will make all the PEP adjustments, which the system failed to make in the first two-and-a-half years of the prospective payment system, at the outset. But the adjusted claims will be held so HHAs can review them via electronic access to the claims system.

    The claims "will be held in status/location S B0098," RHHI Cahaba GBA explains in a posting on its Web site. "Claims can be reviewed through the Claims (12) Inquiry Menu screen (MAP 1741) in the Fiscal Intermediary Standard System (FISS)."

    RHHI Palmetto GBA expects to have the claimed adjusted the weekend of July 12, and to put them in hold status for agencies to look at "shortly after," a Palmetto spokesperson tells Eli.

  • Review. Once the RHHIs give notice that the PEP adjusted claims are in the system, agencies should carefully look over the claims. "HHAs are strongly encouraged to review the claims suspended in status/location S B0098 to ensure that they are in agreement with the RHHI that a PEP adjustment is appropriate," Cahaba urges.

    Gaboury applauds the RHHIs for using a specific code to identify the PEPs for review.

  • Dispute resolution. If agencies don't agree that an episode should have been PEP'd, they should contact the intermediary. "Before calling a [customer] representative, please be prepared to explain why you believe the PEP adjustment is not appropriate," Cahaba says.

  • Weekly recoveries. After giving agencies a week or so to look over their PEPs, the RHHIs will randomly select claims to recoup every week for two years. Spacing the takebacks out over 24 months should reduce the hardship to HHAs, CMS says.

    Cahaba expects to release 500 to 700 claims per week, while Palmetto says its figure will be closer to 750 claims per week.

    RHHI United Government Services says if a provider has an extraordinarily large amount of PEP adjustments, the intermediary will take pains to make sure the recoveries are spaced out to reduce cash flow problems.

    This process will help agencies deal with PEPs - but only if they know it exists before RHHIs begin recouping PEP funds, Gaboury stresses. "My biggest concern is that agencies won't find out until too late how to do it," she says.

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