Home Health & Hospice Week

Determining patients' admission sources accurately is going to pose problems, commenters on the HH PPS proposed rule signaled.

Under HHGM, the claims system would check for a qualifying inpatient stay before processing a claim. But of course, facilities may not have billed for the stay yet, so claims will be reimbursed at the lower community source level rather than the higher institution source level. HHGM "calls for agencies to rely on institutional providers to submit timely claims to Medicare for the patient's prior facility stay," criticized SpiriTrust Lutheran Home Care in Pennsylvania in its comment letter. Agencies would face "the ongoing threat that home health payments could be retroactively adjusted and the patient's period(s) 'recategorized' as a community stay if the facility claim is not submitted correctly."

CMS has suggested a solution for having to rely on the facility's billing - allowing "HHAs to manually

indicate on Medicare home health claims an institutional admission source prior to an acute/post-acute Medicare claim, if any, being processed by Medicare systems." CMS and its contractors would use medical review to police the use of the code.

That comes with its own whole host of problems. If Medicare requires an eventual reconciliation, "the HHA should not be held responsible and possibly subject to post-payment medical review for instances in which it manually indicates on the claim an institutional admission source, and the institution's claim for an acute/post-acute stay is subsequently denied or not filed in a timely manner," the American Physical Therapy Association urged (see more on that problem, p. 297).

Kindred at Home "is concerned about reimbursement and resource implications when a patient has had what he or she perceived to be an inpatient stay, but the hospital has billed the stay as observation status, which would not qualify for an institutional payment in the proposed rule," the publicly traded company said in its comment letter. "This all-too-common scenario could result in the home health provider erroneously billing for 'institutional' services."

Kindred and others urged CMS to include observation stays in its "institutional" category.

The complicated job of trying to accurately identify admission sources and make sure they are billed correctly will "create an additional administrative burden and create claims errors, rejections, and unnecessary audits," criticized commenter Perry Flowers from Texas.