Home Health & Hospice Week

The Centers for Medicare & Medicaid Services is offering suppliers a stop-gap solution to home health bundling problems while it works on a permanent answer to the reimbursement-robbing quandary.

If home medical equipment dealers furnish supplies to a Medicare patient who is under a home health plan of care, the system denies dealers' claims for any items bundled into the prospective payment system. The same goes for Part B therapy services.

Suppliers have no way to check if their patients are under a home health episode, fumes billing expert Jane Wilkinson Bunch of Kennesaw, GA-based JB&CS. "We are flying blind," Bunch tells Eli. That means suppliers don't find out until after they've furnished the supplies and sent in the bill that they won't receive Medicare payment for them.

In the long run, CMS "plans to make available" patients' home health information through the Eligibility Benefit Inquiry/Response (270/271) Transaction System, CMS says in March 7 program memorandum B-03-021.

Suppliers eagerly look forward to having access to this information, says Roberta Domos of Domos HME Consulting in Redmond, CA. Being able to quickly figure out if their clients are under a home health plan of care would be a big relief, since suppliers could direct patients to obtain bundled supplies from their home health agencies or to pay out of pocket for them. "Payment for the services denied by Medicare may be sought from the beneficiary, but you should advise them of their obligation for payment prior to delivering the service," CMS instructs carriers to tell suppliers and therapists in an upcoming bulletin.

Unfortunately, the system CMS plans to use to convey the information may not be up the job, predicts consultant Lisa Thomas-Payne with Albuquerque, NM-based Medical Reimbursement Systems. It currently contains outdated and unreliable information about items such as patients' secondary payor and Medicare managed care status, Thomas-Payne contends.

And CMS allows only participating suppliers to access the system. "This means the supplier must agree to accept Medicare Part B assignment 100 percent of the time for any Medicare patient they service regardless of the reimbursement, coverage or documentation issues associated with servicing that patient," Thomas-Payne explains. "In essence, a [participating] supplier can never do a private or retail transaction with a Medicare patient."

Due to those restrictions, the participating supplier enrollment rate is very low, Thomas-Payne says. That means relatively few suppliers would even be able to access the home health information when CMS gets it on the system.

And right now, CMS hasn't said when that will happen anyway. The memo offers no specific deadline, and some experts suspect it is a stall tactic while the agency works on higher-priority items.

In the short term, CMS urges suppliers and therapists to continue doing what they should already be doing - asking patients about their home health status. "Remember, you are responsible for determining if the beneficiary you wish to serve is eligible to receive additional Medicare payment for your services," CMS says.

Suppliers should check on home health status monthly, recommends Domos. At the least, they should determine eligibility at the start of service and when contacting beneficiaries about refills, she says.

But suppliers have no way of gauging the accuracy of what the patient tells them, bemoans Bunch. She compares the bundling situation to asking patients if they've previously acquired HME to avoid same or similar denials. "You can ask a patient if they have ever had any HME in the past, and they may say no while sitting in a wheelchair," she laments.

CMS does offer a last-ditch option for suppliers who are especially suspicious of a client's information. They now can call up their carriers and ask for the patient's home health status from a customer representative.

Suppliers may be hesitant to use this option since CMS stresses that it is a "last resort" tool. But it's likely the agency simply is trying to head off a barrage of calls from suppliers and therapists who haven't made any efforts to obtain the home health status from the patient first, Domos offers.

The helpfulness of this alternative will depend on carriers' responsiveness to the calls. "If it is efficient and done in a manner that is beneficial, then it may be a blessing," Bunch forecasts. But if suppliers have to wait on hold for 45 minutes for the information, it will overwhelm their already-overtaxed resources, she protests.

CMS has directed carriers to add a prompt to their eligibility hotlines by April 1, directing callers to speak to a live agent about home health status. Carriers also should complete training of customer service reps by that date, the memo says.

Providers confused about what codes are covered in home health PPS bundling can consult a master list on CMS' Web site at http://cms.hhs.gov/medlearn/refhha.asp. The zipped Excel file, last updated in January, shows a complete list of all codes ever bundled along with associated predecessor and successor codes.