Home Health & Hospice Week

LUPA PEPs safe from recoveries. 

By the time you read this, it may be too late to see how much money your intermediary will be taking off your bottom line due to partial episode payment adjustments.

It's important for home health agencies to go online and peruse the claims their regional home health intermediary is holding for PEP takebacks. All the RHHIs have issued instructions on how to check those PEPs (see box, this page).

By looking at those claims, HHAs are able to see how much money the RHHIs will take back over the next 24 months as they gradually release the adjustments. They are recovering the PEP money now because the claims processing system failed to make the adjustments in the first two-and-a-half years of the prospective payment system.

But at least one intermediary is offering only a narrow window of opportunity for agencies to look over their pending PEP adjustments. HHAs served by Palmetto GBA have only from July 17 to July 28 to peruse the PEP'd claims, the RHHI says in a notice posted on its Web site and dated July 15.

Giving agencies only two days notice that they have a little over a week to look at the claims isn't enough, critics charge. It takes time for HHAs to find out that the information is even available, let alone check it online. "I am positive that is not enough time," says Melanie Golson of the Home Care Association of Alabama.

On the other hand, HHAs that really care about this issue have been watching Palmetto's Web site like hawks ever since the PEP schedule was announced, notes Karen Hinkle of the Kentucky Home Health Association. They will be on top of the notices and the timeframe should be adequate. "Hopefully they are checking the site and printing out the list of their claims affected," Hinkle says.

RHHI Cahaba GBA made the PEPs available online July 7, and United Government Services made them available July 22. UGS HHAs' claims will sit in the location that is accessible to HHAs until the intermediary pulls them up to adjust (and recoup) them, a UGS official confirms. "Some claims will be there for two years ... until they get pulled up," the source explains.

But the situation is different for agencies served by Associated Hospital Service of Maine. Because the RHHI accidentally ran most of its PEP adjustments back in April, it can't run them again.

Instead, AHS will withhold 5 percent of an agency's normal payment every week, the RHHI says in a July 18 Medimessage. That withholding "closely simulates the small batch process" that other RHHIs are using, AHS says. The withholds will terminate when an HHA's PEP debt is fully recovered.

There are still a small number of PEP claims that haven't processed, AHS adds. The RHHI will wait to process those, and reclaim any resulting PEP funds, until after the 5 percent withhold is complete.

Most of those claims are low utilization payment adjustments (LUPAs) anyway, AHS says. For all RHHIs, PEP adjustments made to LUPAs won't result in any reimbursement being taken back. That's because HHAs received per-visit payments only for the fewer than five visits made.

AHS' system of taking back PEP funds is more consistent than other RHHIs' random batches, notes Susan Young with the Home Care Association of New Hampshire. But there's nothing good about money being taken back, whatever the method.

Young expects the highest PEP recoupment in the state to be about $150,000. One agency in Massachusetts will see a PEP takeback of $450,000, and others' recoupments may be even higher.

Palmetto says it will process 725 PEP claims per week while UGS says it will process 550. UGS and AHS indicate the takebacks will begin Aug. 1.

Add Dates After Processing 

After a PEP'd claim cycles through the payment system, HHAs will be able to adjust it to add visit dates - which could significantly boost reimbursement, Palmetto and UGS tell providers in their PEP notices.

"Home health agencies may have initially failed to submit one or more visits on the original final claim for an episode of care and then never submitted an adjustment to add the visit(s) (because under the home health prospective payment system these visits would not normally alter their payment for the episode)," Palmetto notes.

But those visits may have significant impact on payment if the episode is PEP'd. "In these cases, [HHAs] may submit an adjustment claim to add visits after the processing of a PEP recovery adjustment," Palmetto offers.

If the claim is too old to meet Medicare's timely filing deadline, agencies must indicate in the remarks field that it's an adjustment for a PEP recovery. An exception will be granted for the Centers for Medicare & Medicaid Services' administrative error.

But home care advocates still are hoping to fight those PEP recoveries that are more than a year old, says William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law.

NAHC is preparing a model appeals kit for claims that CMS shouldn't be able to touch because it doesn't have good cause to reopen them after one year, Dombi tells Eli (see Eli's HCW, Vol. XII, No. 24, p. 187).

And NAHC continues to plan a lawsuit based on those grounds, Dombi says. How the suit will proceed will depend on exactly how CMS and the intermediaries handle the recoveries, he notes.

Docs Get Special Treatment 

Home care providers still express indignation that CMS agreed not to recover physicians' recent overpayments while staying bent on taking back HHA PEP funds.

"Why are they recouping home health payments and not physician payments?" Young demands. "It certainly raises some questions."

NAHC has been told CMS is giving physicians special treatment because the docs' overpayments involved small amounts of money and large numbers of claims, Dombi reports. That means the cost for CMS to recover the physician payments would outweigh the recoveries themselves.

And physicians' overpayments will be recouped in the process for updating doc rates for inflation next year, CMS reportedly told NAHC. "I find neither of these explanations convincing," Dombi maintains.