Home Health & Hospice Week

Claims system overhauled to curb hospital stay, Medicare Advantage-related overpayments.

If you’re trying to figure out why some of your claims aren’t paying, it may be due to two new Medicare transmittals that took effect Jan. 1. Those transmittals implement procedures that reject claims that overlap with patient stays in hospitals or for patients in managed care plans.

Hospitals: Before Jan. 1, the Medicare system rejected claims with overlapping dates only when the hospital submitted its claim first, noted the Centers for Medicare & Medicaid Services in CR 8699 issued Aug. 1. And the system didn’t check inpatient days that occurred in a swing bed.

Now, the system compares incoming facility claims against home health claims. “If any home health visit dates are found to fall within the inpatient claim dates, the contractor shall … create an adjustment to the home health claim and reject the line items for any visits,” CMS said in the CR at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3005CP.pdf.

Medicare Advantage: Medicare doesn’t pay HHA claims when the patient’s episode falls entirely within a Medicare Advantage enrollment period, CMS reviewed in Aug. 1 CR 8710. But before Jan. 1, the system would still pay requests for anticipated payment (RAPs) for such episodes. The system would then recoup the RAP amount when rejecting the final claim or when no final claim was filed by the 120-day deadline.

Now CMS has resolved the “pay and chase situation” by revising “Original Medicare systems to ensure that RAPs with ‘From’ dates falling within Medicare Advantage enrollment periods are pro-cessed but are paid at zero percent,” CMS explained in the CR. “This will allow the final claim to be received and rejected appropriately, but will prevent any program vulnerability.”

Plus: “The requirements add remittance ad-vice coding to zero-paid RAPs processed in Medicare Secondary Payer situations, so that the two situations can be distinguished,” CMS added. “In the future, CMS will seek a new alert remittance advice remark code to specifically identify the Medicare Advantage cases also,” the agency says in the CR at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3010CP.pdf.