Home Health & Hospice Week

CMS official offers solutions to common MA problems.

You could be messing up your OASIS data if you don't pay careful attention to reporting rules for Medicare managed care plans.

Filling out M0063 (Medicare Number) and M0150 (Current Payment Sources for Home Care) trips up many home health agencies, said Pat Sevast with the Centers for Medicare & Medicaid Services at a recent conference. "I get these questions every day," Sevast told attendees of the National Association for Home Care & Hospice's annual policy conference in Washington, DC April 27.

Do this: For M0063, use the patient's Medicare number, not his number for the MA plan, Sevast emphasized. "Do not try to force a 15-digit number in there," she counseled.

The Medicare number will be marked "Claim No." on his Medicare card, CMS tells agencies in Chapter 8 of the OASIS User's Manual.

If the patient's Medicare number isn't available, choose the "NA - No Medicare" box. "Do not enter the HMO identification number," CMS stresses. This is true even if the managed care plan is a private-fee-for-service (PFFS) plan, Sevast explained.

"There's a huge amount of confusion when a new plan moves into a state," Sevast lamented.

Answering M0150 can also be tricky. Use the following test, Sevast advised: If your reimbursement claim goes to a Medicare intermediary, check number one (Medicare [traditional fee-for-service]). If you submit the claim to an insurance plan, check number two (Medicare [HMO/managed care])--even if it's a PFFS managed care plan.

SOC rules: Finally, when a patient changes from a Medicare managed care plan to Medicare, CMS requires a new start of care (SOC). When the patient goes from Medicare to a managed care plan, that plan dictates the new admission requirements. Contact those companies to find out what to do, Sevast advised.

Here to Stay?

If the trend in rising Medicare managed care enrollment continues, particularly increased PFFS enrollment, you may be dealing with more of these patients, experts say.

Wait and see: But Medicare payment cuts to such plans may nip that growth in the bud. Following Senate and House hearings last month criticizing the plans, and particularly plans' marketing practices, lawmakers have expressed a desire to reduce Medicare managed care payment rates starting in 2008 (see Eli's HCW, Vol. XVI, No. 19).

And CMS has proposed additional compliance requirements for MA plans. Under the new rules, plans would have to more clearly explain the differences between traditional Medicare and the PFFS plans.

"We may see history repeat itself," notes financial consultant Tom Boyd with Boyd & Nicholas in Rohnert Park, CA. In the 1990s, managed care organizations jumped into the Medicare market when payment rates were high, then quickly abandoned it when rates were reduced. "It could happen again," Boyd predicts.

Uphill battle: In the meantime HHAs are struggling to obtain payment from a multitude of plans with complex billing requirements or just plain slow payment processes, providers complain.