Home Health & Hospice Week

Next Medicare claims processing software fix is due Feb. 4.

Prospective payment system claims from 2008 finally have a green light, but if you're still not getting paid, you're not alone.

Home health PPS requests for anticipated payment and claims should be processing now, a Centers for Medicare & Medicaid Services source tells Eli.

"The claims problems are all but gone," cheers Baton Rouge, LA-based software vendor Lewis Computer Services Inc. "Cash flow is restored for the most part," reports Bob Wardwell with the Visiting Nurse Associations of America.

"The worst of it is over," agrees William Dombi, vice president for law with the National Association for Home Care & Hospice. PPS claims from 2008 should go through and intermediaries are clearing their backlog of held claims.

Impact: Agencies that saw 100 percent of their 2008 RAPs and many final claims returned or held saw some serious consequences, Dombi notes. Some providers couldn't meet payroll and had to ask staff to hold on until cash came through. Others stopped taking new admissions until their claims started processing.

"We hope those patients found home care with other providers," but there's no way to know for sure, Dombi tells Eli.

Still more agencies tapped their lines of credit to stay afloat, which will cost them in financing fees. Some HHAs succeeded in obtaining accelerated payments from Medicare, but many were discouraged from even applying for the payments by intermediary staff, Dombi relates.

Even agencies that weren't strapped for cash had to put in extra man-hours trying to figure out what was happening with their claims.

The good news: "No one closed," Dombi says.

Nailing Down Billing Errors Proves Tricky

Despite the "all clear" on claims from CMS, many providers still aren't seeing all of their cash--and sometimes any cash at all--coming in, industry experts report.

"Not everyone is getting what they should yet," Dombi notes.

"Some agencies aren't getting paid and it's hard to know why," says billing expert Bobby Dusek in Abilene, TX. "They are trying to figure it out."

The hold-up could be occurring anywhere along the billing chain--in the provider's software or claims data entry, the submission process or Medicare's claims processing, Dusek points out. Pinpointing the exact reason can be frustrating for agencies.

"Now that the bigger problems are taken care of, smaller problems are surfacing," Dombi observes. And whether those problems lie with Medicare or the provider is up for grabs.

A few new claims system problems have been identified. One is a problem with the nonroutine supplies (NRS) digit in the HIPPS code--the last digit.

Under PPS, the system should allow that fifth digit to differ between the RAP and the final claim, regional home health intermediary Cahaba GBA ex-plains in a Jan. 29 message to agencies. That's so agencies can indicate that they did or did not furnish NRS during the episode.

Background: Whether the HIPPS code contains a number (indicating supplies were not furnished) or a letter (indicating supplies were furnished) won't make a difference to the payment amount, but it is required to tell the system whether the NRS edit will apply to the claim. The NRS edit, which will start in April, looks to see whether the agency included a supplies line-item charge on the claim if it furnished supplies during the episode. The requirement aims to help CMS gather more information to set future NRS payment levels.

But the PPS system currently won't let final claims have a different last digit in the HIPPS code as it's supposed to. Instead, such claims will return to provider (RTP) with reason code 38107, Cahaba explains.

Solution: With some extra work, agencies can get these claims paid, Cahaba instructs. They can switch the last digit back to match the RAP, since NRS edits don't start until April.

This is a temporary work-around, notes Wardwell, a former top CMS official who headed up PPS' implementation in 2000.

Or providers can just wait for a Medicare software fix to correct the problem. The next PPS software update is scheduled to take place Feb. 4, the CMS official confirms.

The software correction should address the NRS issue, plus solve other payment problems that CMS has already identified. Those include the system failing to auto-adjust claims upward when therapy visits exceed 20, to wage adjust low utilization payment adjustment (LUPA) add-ons, to include the LUPA add-on for partial episode payment (PEP) proration, and to apply NRS add-ons to 2008 claims only.

Small favors: The system has been erroneously assigning the NRS add-on to claims that began in 2007, Dombi explains. But at least it only adds the lowest NRS level of $14.92, so hopefully overpayments haven't racked up too quickly.

Whether the fix will address another new problem concerning the Common Working File is unclear.

HHAs are seeing claims return because the beneficiary name and Medicare number don't match or the beneficiary isn't found in CWF, Dombi reports. But these RTPs are for longstanding patients who have never had billing problems before. Those returns show reason code F5052 and M5052.

And claims delays may not be due to PPS problems at all, but rather NPI edits that went into effect Jan. 1, Wardwell notes. "CMS is so flaming edit-happy they drive themselves and the rest of us nuts," he laments.

Brace For Further Cash Hold-Ups

It's not over: There probably are further "loose ends" and "hidden issues" ahead, Wardwell predicts.

Every major software change comes with a host of problems and this one is no exception, Dombi observes. That's why NAHC urged CMS to make easy interim payments available for agencies.

"All of this was predictable," Dombi says of the payment holds.

Update: CMS has issued the newest version of the PPS grouper logic, pseudocode and related documents, the agency says. But CMS has yet to post the actual grouper software. It is "forthcoming," the agency promises in a Jan. 30 message to providers.

Note: The logic and pseudocode are at www.cms.hhs.gov/HomeHealthPPS/05_CaseMixGrouperSoftware.asp.

To learn more about NRS billing, sign up for Eli's March audioconference on the topic.