Home Health & Hospice Week

Question: What happens if a patient joins HMO Option C during an episode but you don't find out until it's time to bill the final claim? Could you bill the HMO for the rest of the services you provide after the switch to the Medicare Advantage plan?

-- Puzzled Subscriber

Answer: This is a problem that plagues many home health agencies, noted reimbursement consultant Michelle Enger in a recent Eli-sponsored audioconference. The first way to ensure you're getting your rightful reimbursement is to bill Medicare for the portion of the episode that was furnished under traditional fee-for-service using a partial episode payment (PEP) adjustment.

"I find a lot of home health agencies don't realize they can bill the portion of the days or weeks the patient was under your care and under traditional Medicare to Medicare PPS and it would be a PEP situation," said Enger, with Optimal Reimbursement Strategies in Clearwater, FL. "The Medicare Advantage plan picks them up on the first of the month in the following month. So please be aware that you can send in that claim for partial episode payment if they decide to pick up a Medicare Advantage plan halfway through your episode."

After the MA plan coverage kicks in, you can bill that plan if you have a contract with it, Enger explained. Or you can bill as an out-of-network provider.

Don't forget: When a patient switches the other way, from an MA plan to regular Medicare, you can bill the HMO for the first part of the episode, Enger reminded listeners. Many providers don't realize they can secure payment from managed care plans with PEPs too.

Note: Please submit your reader questions on any home care topic to editor Rebecca Johnson at rebeccaj@eliresearch.com.