Home Health & Hospice Week

The complexity of the prospective payment system after this year's revisions may make it tempting to accept claims adjustments from Medicare with no questions asked, but that could be a big mistake.

If your claims don't match what you thought the payment should be or what your computer system says, "you really need to reconcile," urged Michelle Enger, reimbursement consultant with Optimal Reimbursement Strategies in Clearwater, FL.

"I would strongly suggest not just doing an adjustment and getting rid of it and hoping that that was the correct thing to do," maintained Enger in an Eli-sponsored audioconference this summer. "You really need to have your biller go in and investigate."

Follow these steps to investigate your affected claims:

1. Keep a spreadsheet of the claims with mysterious adjustments. Don't move claims off the list until you've gotten to the bottom of the adjustment.

2. Investigate discrepancies between the billed claim and the payment. This is essential under the PPS revisions because many claims are downcoding, Enger said.

3. Access the patient's claim via Direct Data Entry (DDE). Go to the claim revenue screen (claim page 2) and then select claim inquiry (menu option 12), Enger instructed. Press the F2 key to view the claim on two pages -- MAP 171D (right page) and MAP 171A (left page).

Tip: The arrow keys don't work to navigate within the claim. You have to use F10 to scroll left and F11 to scroll right, Enger explained.

4. Determine the payment differences. Page 171D will show you what HIPPS code you billed and 171A will show you what HIPPS code Medicare paid you. "A lot of home health agency employees are not aware of how to do this," Enger said.

Resource: For a copy of Enger's examples that show where to find the HIPPS codes on the screens, email editor Rebecca Johnson at rebeccaj@eliresearch.com with "HIPPS Code Examples" in the subject line.

"I think this is very, very important to be able to go in here and ... determine if it was a true correct episodic payment adjustment," Enger said. For example, maybe your therapists made fewer visits than projected and the adjustment was warranted.

It's important to know if it was a payment system error, such as the late/early episode problem, so you can track the payment, request a change if necessary, or wait for promised mass adjustments.