Home Health & Hospice Week

How ‘related’ are your claims?

 Financial implications for your denials may get much steeper, thanks to a new CMS directive on related claims.

Medicare contractors that have denied a claim under medical review "have the discretion to deny other related claims submitted before or after the claim in question," the Centers for Medicare & Medicaid Services instructs in CR 8425 issued Feb. 5. "If documentation associated with one claim can be used to validate another claim, those claims may be considered ‘related,’" CMS says.

"The MAC, Recovery Auditor, and ZPIC are not required to request additional documentation for the related claims before issuing a denial for the related claims," CMS adds.

Bad news: "This policy change could have significant implications for home health and hospice providers since they often submit multiple claims for a single incident of illness — for example, submitting claims for several episodes for home health services or several months for hospice care," the National Association for Home Care & Hospice says. "If the contractor determines one claim does not meet Medicare payment criteria, any related claim could also be denied — such as when an episode is denied because it fails to meet the F2F encounter criteria. Claims for subsequent episodes could also be automatically denied."

The CR is at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R505PI.pdf.