Home Health & Hospice Week

Caps and outliers won’t trip you up.

Cap- and PIP-related concerns for home health agencies and hospices in the 60-day overpayment regulation have been laid to rest by the new final rule on the requirement.

Recap: Back in 2012, the Centers for Medicare & Medicaid Services proposed a rule requiring Medicare providers to report and refund selfidentified overpayments within 60 days from the date the provider identifies the overpayment, or the date the corresponding cost report is due. Then a year ago, CMS pushed back the final rule publication date to 2016 (see Eli’s HCW, Vol. XXIV, No. 18).

Now CMS has finally published the final rule, and it contains some relief for HHAs and hospices. The rule takes effect March 14, although the underlying statute has been in effect since 2010.

Issue #1: “Home health and hospice providers raised concerns with the proposed rule regarding the rule’s effect on the hospice annual cap, the home health outlier revenue cap, and requests for anticipated payments (RAPs),” notes the National Association for Home Care & Hospice in its member newsletter. “Hospices and home health agencies have no way of knowing whether they have received a cap overpayment, or the amount, until they are notified by the MAC.”

Response: “The hospice and home health cap determinations are made at the end of the year and it is possible that the provider may not be aware of the cap status until their MAC calculates the final cap amount,” CMS acknowledges in the final rule published in the Feb. 12 Federal Register. “Therefore, the provider is not responsible to report and refund the overpayment until they have received the cap determination from their MAC. There can be no applicable reconciliation until the final cap amount is determined.”

Issue #2: “Commenters questioned how providers that receive periodic interim payments (PIP) would be expected to return any overpayments,” CMS notes in the final rule. “Under the statutory and proposed regulatory definitions of ‘overpayment,’ during any cost reporting period, no overpayment exists until the provider submits its cost report.”

Response: “Overpayments as a result of PIP payments would be reported and returned at the time the initial cost report is due,” CMS agrees. “There is no applicable reconciliation until the PIP payments are dealt with in the cost report process.” But you’re not totally off the hook for PIPrelated overpayments. “If a provider is aware that their PIP payment may not be accurate, they should continue with normal business practices and inform its MAC of the issue,” CMS instructs in the rule.

Issue #3: HHAs also had concerns about outlier-related overpayments.

Response: “An overpayment as a result of an outlier reconciliation would be identified once the provider receives that information from its MAC as part of the cost report settlement process,” CMS clarifies. “The provider is not responsible for attempting to identify the cost report outlier reconciliation overpayment in advance of the MAC’s reconciliation calculation.”

But “if the provider identifies an inaccurate outlier claim payment, the provider must follow the overpayment payment reporting process for claims,” CMS adds.

Note: See the rule at www.gpo.gov/fdsys/pkg/FR-2016-02-12/pdf/2016-02789.pdf.