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Home Health & Hospice Week

Prospective Payment System:

MEDICARE CLAIMS SYSTEM MELTDOWN HOLDS UP PPS PAYMENTS

Published on Thu Jan 10, 2008

Intermediaries are sitting on RAPs while CMS scrambles to fix the system.

The bad news home health agencies have been dreading has become a reality--a major breakdown of the Medicare claims payment system under the prospective payment system changes.

Regional home health intermediaries are holding requests for anticipated payment (RAPs) due to payment problems, bringing agencies' cash flow to a screeching halt. First, RHHIs are holding all RAPs while they do more validation and testing of the payment software, the Centers for Medicare & Medicaid Services revealed in the Jan. 9 home health Open Door Forum that drew 588 callers. They generally will release RAPs Jan. 14 with agencies receiving those payments by mid-week, CMS' Wil Gehne explained.

Second, CMS has discovered specific problems centering on technical issues with HIPPS code termination dates and Core-Based Statistical Areas (CBSAs) for rural areas, Gehne said.. RHHIs will have the fixes for those by Jan. 11, then test and implement them the following week. CMS described the problems as "minor" and Gehne expected them to cause "very little delay in payment overall."

But at least one regional home health intermediary is telling HHAs and hospices to not submit any post-Jan. 1 claims for now, reported Bob Wardwell with the Visiting Nurse Associations of America in the forum. And the National Association for Home Care & Hospice describes the problems as "serious."

NAHC is pushing CMS to trigger a contingency payment plan for HHAs. In the meantime, agencies should contact their intermediaries to prepare accelerated payments in case the claims outage drags on. But that may not be enough, NAHC warns. "Accelerated payment procedures ... may not be capable of providing a quick turnaround in payment to address emergency needs," warns NAHC's William Dombi in a message to members.

Bright side: The claims holdup should make providers feel better if they are one of the many that haven't managed to bill under the new PPS changes. Providers that have been able to submit RAPs are having to wait for payment anyway.

HHAs already knew they'd have to wait until at least Jan. 7 to receive their first payments. Medicare didn't install the payment system software changes until the first weekend of January, meaning the first RAPs didn't process until the evening of Jan. 7, a CMS official explains to Eli. Installing the software update during the first weekend is "business as usual," the CMS source says. "We always install quarterly updates the first weekend of a quarter." It just happens that the weekend fell later in the month than usual.

HHAs may have to lean on the cash reserves financial experts advised them to build up to carry them through any PPS transition troubles (see Eli's HCW, Vol. XVI, No. 43).

Another problem: HHAs that didn't have their National Provider Identifiers yet also saw submission problems, notes Lynn Olson with Astrid Medical Services. CMS began requiring them in primary fields Jan. 1. It's NPI issues that put RAPs on hold until Jan. 7, Gehne said in the forum.

Note: For more on the payment system problems, see next week's issue of Eli's Home Care Week.

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