Home Health & Hospice Week

HAVEN will be out Dec. 21, CMS pledges.

Home health agencies that will ring in the new year with a PPS billing crisis instead of champagne have three options for Medicare reimbursement help.

But those options apply when HHAs' own billing software fails, the Centers for Medicare & Medicaid Services explains in a new PPS billing failure contingency plan posted to its Web site Dec. 18.

Not good enough: CMS doesn't lay out any options for failure on the part of the regional home health intermediaries' payment systems, worries the National Association for Home Care & Hospice. In a recent meeting, "NAHC urged CMS to consider development of a plan that would identify action in the event of intermediary failures," the trade group says in its member newsletter.

A CMS staffer recently expressed confidence that RHHIs' systems would be ready for prospective payment system changes Jan. 1 (see Eli's HCW, Vol. XVI, No. 42).

But anyone who has gone through a billing transition knows that confidence may be misplaced, says consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas.

CMS offers these three options, which will apply until March 31, if your billing software isn't ready to handle the PPS changes:

1) Use HAVEN. Use the new HAVEN software, which CMS planned at press time to release Dec. 21, to derive your new PPS HIPPS code. Then manually enter that code on a request for anticipated payment (RAP) via the Direct Data Entry (DDE) system.

2) Use a default HIPPS code. If using HAVEN isn't "feasible," you can use on RAPs a default HIPPS code chosen by CMS. HIPPS code 1CGKT reflects the national median case mix weight (0.9896) and the non-routine medical supply (NRS) level 2, which pays $51.

CMS chose this code, which corresponds to HHRG C3F2S1, because it was "among the top five highest-frequency case-mix groups in our impact sample," it says. The agency chose the median rather than mean weight because it is more representative of all claims, CMS maintains.

HHAs choosing this option would again have to submit their RAPs via DDE. They would also have to use a "placeholder" treatment authorization code of 11AA11AA11AAAAAAAA.

While the option would extend to March 31, the system would continue the current practice of recouping RAP payments after 60 days if no final claim is filed. Since the default code option applies only to RAPs, not final claims, a RAP could time out during the option period.

HHAs unready to bill accurately could resubmit the RAP after the system canceled it, CMS suggests.

Otherwise, agencies with updated software can cancel the default-code RAP and submit an accurate one, or just wait for the system to auto-cancel it before submitting an accurate new one, CMS instructs.

3) Accelerated payments. Agencies can go through "existing procedures" to obtain accelerated payments, CMS offers. No special provisions would be added for the PPS transition.

The problem: Agencies without DDE access won't be able to use the first or second option, Boyd criticizes. "It's sad that not all HHAs have DDE," Boyd tells Eli. "Not all HHAs will overcome the pending disruption."

But CMS notes that "85 percent or more" of agencies have current access to DDE. "These options will be available to the great majority of HHAs without special action," the agency maintains.

Financial consultant Melinda Gaboury has been advising agencies for months to have DDE and HAVEN access in place as a backup plan, she says. Most agencies should be able to use HAVEN and not mess around with the default HIPPS codes, expects Gaboury, with Healthcare Provider Solutions in Nashville, TN.

Get going: Agencies that want to have their backup billing plan in place but that don't currently have DDE access should hop on it. "Apply to [your] RHHI for access as soon as possible," CMS urges. "New applications for DDE access require approximately two weeks to be processed."

Note: The contingency plan is online at www.cms.hhs.gov/HomeHealthPPS/downloads/GuidanceforHHAs_Posting_12-18-2007.pdf.