Home Health & Hospice Week

Question: What exactly happens at the quarterly reconciliation for outliers? If a provider has an$8,000 outlier payment for a single episode on "Hold" because he is above 10 percent and he goes $3,000 below the 10 percent, does he get paid the $3,000?

Answer: At the quarterly reconciliation, any claims that had outlier amounts withheld when the claim paid are reprocessed to determine whether the outlier has become eligible for payment based on whether the agency has exceeded the 10 percent outlier cap, explains billing expert M. Aaron Little with BKD in Springfield, Mo. "If the agency is below the cap, then the previously unpaid outliers are paid. Otherwise, they go into a pool for potential payment consideration at the next quarterly reconciliation."

So in the example, the $3,000 would be paid at the next quarterly reconciliation, Little says. CMS's 2009 transmittal on how the outlier process works is online at www.cms.hhs.gov/transmittals/downloads/R1883CP.pdf and a related MLN Matters article is at MattersArticles/downloads/MM6759.pdf.