Home Health & Hospice Week

You may be on the hook for hospitals' billing problems under HHGM.

If you think determining an institutional stay for your patients under HHGM will be tricky when Medicare is the payer, just consider how much more difficult it might be when Medicare is not.

According to the 2018 HH PPS proposed rule, the Home Health Groupings Model case mix system would count both Medicare and non-Medicare-paid institutional stays toward the "institutional" designation. That could make a 20 percent difference to your patient level (see story, p. 294).

Under HHGM, HHAs would use newly created occurrence codes "for beneficiaries with acute /post-acute care stays paid by other payers, such as the Veterans Administration," the Centers for Medicare & Medicaid Services said in the proposed rule issued in July.

HHAs would also use the occurrence codes for Medicare inpatient stays that the providers haven't billed for yet. Those stays should eventually show up in the Medicare claims system, and the claims system will automatically adjust corresponding home health claims, the rule said.

For non-Medicare-paid stays, agencies must submit the claims with the occurrence code, CMS confirmed in the rule. But "we expect home health agencies would utilize discharge summaries from institutional providers to inform the usage of these occurrence codes," the rule specified. "We note that these discharge documents should already be part of the beneficiary's home health medical record."

In cases of non-Medicare payers, or when Medicare payers' inpatient claims are denied or not even filed, CMS "may conduct post-payment medical review of the home health claim to determine whether the admission was in fact preceded by an institutional stay occurring within 14 days of the home health admission," the rule said. "If upon medical review a determination is made that the admission was not from an institutional setting, we would take appropriate administrative action, including correcting any improper payments and potentially referring the provider to another CMS review contractor for further review or investigation."

This provision is just too much, says the American Physical Therapy Association. HHAs should not be on the hook when facilities fail to file their claims, or file them late, the trade group blasted. "Denial ... could be for a number of reasons of which the HHA has no knowledge or involvement.

The denial of an institutional claim, as well as the timely filing of a claim, is outside of the control of the HHA. It is unreasonable for CMS to subject HHAs to post-payment medical review and face potential penalization for an acute/post-acute institution's actions or inactions," APTA said in its letter.

"Further, we request that home health claims with non-Medicare institutional admission sources be exempt from post-payment medical review, given the inherent difficulties associated with accurately assessing whether the non-Medicare institutional stay satisfied the payer's coverage requirements, was timely filed, etc.," APTA said.

APTA also encouraged CMS "to discuss within final rulemaking the process by which HHAs should verify a non-Medicare institutional stay."

Plus: CMS should "clarify within the final rule the length of time that a HHA would have to resubmit a home health claim when it learns of a non-Medicare institutional stay occurring within 14 days of the home health admission. Moreover, we urge CMS to provide a detailed discussion related to the timeframe by which Medicare will make payment modifications to a claim when the HHA categorizes a community admission source, but an acute/post-acute Medicare claim for an institutional stay occurring within 14 days of the home health admission is subsequently submitted," APTA urged.

Stay tuned: Commenters and others will see whether CMS heeds their advice when it issues the final rule, expected in November.