Home Health & Hospice Week

Providers hold their breath as Medicare sorts out claims system glitches.

The cash flow gush providers were hoping for Jan. 14 may not have materialized, but Medicare is slowly starting to pay some 2008 claims.

In its Jan. 9 Open Door Forum, the Centers for Medicare & Medicaid Services identified problems with the new claims payment software required for the prospective payment system changes that took effect Jan. 1. And CMS laid out a timeline for resolution of those problems (see Eli's HCW, Vol. XVII, No. 2).

At the time of the forum, regional home health intermediaries were holding all 2008 claims. They were supposed to have a fix for general claims system problems by Jan. 11 and start processing 2008 requests for anticipated payment (RAPs) by Jan. 14, CMS' Wil Gehne said in the forum.

Software corrections for two specific problems, those related to rural Core-Based Statistical Area (CBSA) codes and HIPPS codes for claims straddling 2007-2008, were scheduled to go to RHHIs by Jan. 14, with claims processing by mid-week if the fixes worked. CMS was further investigating reported problems related to the new treatment authorization codes.

"CMS has to be pretty disappointed that after all the assurances by contractors that the new system had been testing out fine, that problems with this significant an impact were not detected," observes Bob Wardwell with the Visiting Nurse Associations of America. Wardwell headed up PPS' original implementation in 2000 as a top CMS official.

What's Happening To Your Claims

The intermediaries did receive the first software patch by Jan. 11, but didn't test it and start releasing RAPs until Jan. 15, reports the National Association for Home Care & Hospice.

CMS also has temporarily lifted the edit on the treatment authorization code so that claims affected by that problem could go through, according to NAHC. Intermediary Palmetto GBA reports on its Web site that those codes are indeed causing problems. It was using Reason Code 30720 to suspend affected claims to Status/Location SM0720 before the edit was lifted.

Still holding: At press time, the intermediaries hadn't started releasing RAPs and claims affected by the CBSA and HIPPS code problems. NAHC reports that claims with CBSA problems still won't be able to process for a while yet because the software patch for the CBSA error didn't work.

But a CMS official told Eli the fixes for those problems would go in Jan. 16 and intermediaries would release the RAPs and claims the same day.

At press time, billing software vendor Lewis Computer Services Inc. reported that not many 2008 RAPs from RHHIs Cahaba GBA, or former National Government Services segments United Government Services and Blue Cross of California have paid. Palmetto was doing a bit better with 28 percent of RAPs clearing, reported the vendor, which has clients all across the country. Most of the non-paying RAPs were due to the CBSA (Reason Code 32038) or treatment authorization (30720) problems.

RAPs from 2007 episodes were faring better, with Palmetto and Cahaba having cleared about 65 percent of 2007 RAPs each. They were still holding up most of the rest for the CBSA issue, Lewis said.

Final claims for 2008 episodes were being paid, but at varying rates. BCC was doing the best while Cahaba was the worst with about 28 percent of final 2008 claims clearing, Lewis reported.

Focus On 2007 Claims First

Those complicated issues have left agencies wondering when their claims will get paid and whether they need to resubmit them to obtain correct payment. Those requirements may vary from intermediary to intermediary, experts warn.

Lots of agencies weren't really ready to submit RAPs until mid-month anyway, notes Nancy Nelson with the Illinois Home Care Council. For patients admitted Jan. 1, by the time agencies review the OASIS, lock it and prepare the 485, they are just beginning to submit RAPs.

But agencies are starting to feel the pinch from the delay. "We are hearing lots of complaints," says Neil Johnson with the Minnesota HomeCare Association.

If many RAPs and claims get held up another 10 days or so, "the screaming will start," predicts Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas.

Do this: Because 2007 claims are paying better than 2008 ones, you should focus your billers' efforts on getting all 2007 claims out the door to bring in the quickest payment, Lewis suggests on its Web site. "With 2007 claims enjoying a higher payment success rate right now, submitting 2007 claims is the safer path to being more cash-productive."

But if your 2007 claims are all squared away, do keep submitting 2008 claims, Lewis advises. "With any luck, all submitted 2008 RAPs will soon be released," the vendor says. "If you can submit 2008 RAPs without delaying your 2007 billing, then submit all you can."

Beware: Now that 2008 RAPs and claims are finally being processed, errors with agencies' software may start coming to light, Lewis noted. Keep an eye out for such problems and discuss them with your vendor.

For example: Lewis is seeing a high rate of claims returned for missing a type of bill (TOB) (Reason Code 30920) and for final claims not matching RAPs (U5391). Scrutinize those for possible software causes, the company recommends.