Home Health & Hospice Week

New York agency learns a $200,000 lesson the hard way from the PRRB.

If you make an error billing Medicare, you'd better catch it in time or wave goodbye to the reimbursement that's rightfully yours.

The Allegany County Department of Health home health agency failed to catch its error in billing home health aide services in time to rebill them and got no help from the Provider Reimbursement Review Board in correcting the problem, according to a recent PRRB decision (2007-D3).

Allegany billed its aide visits from January to September of 2000 at the agency's one-hour aide rate of $30 instead of its per-visit rate of $62.10, the decision says. The error was due to a "software glitch," says the HHA's attorney, Ross Lanzafame of Harter Secrest & Emery in Rochester, NY.

The agency didn't discover the problem until it began reconciling the Provider Statistical & Reim-bursement (PS&R) report with its cost report for the year, it told the Board. However, Allegany's intermediary United Government Services issued the PS&R later than usual due to the switch from the interim payment system (IPS) to the prospective payment system. That meant when the agency found out about the problem, it was too late to rebill the claims at issue.

"The Provider claims they were disadvantaged by the delay in the PS&R and the filing of the FY 2000 cost report," the decision says. "These delays resulted in its being unaware of the error until at least November 2002, long after the deadline for billing."

Loss: UGS decreased the agency's cost report charges to match the PS&R data, resulting in a $206,400 adjustment.

Allegany sought to correct the problem through the cost report, showing why its PS&R data should match the cost report.

But the intermediary said the PS&R was correct based on the submitted claims. "It was a lack of diligence on the Provider's part and the Provider's failure to review information provided to it that caused the 'error' to go undetected until after the time limit for billing had passed," UGS contended.

Allegany could have checked its remittance advices against its claims, reviewed the previous year's cost report that had the same problem or checked a revised adjustment report to find the problems before the billing window closed, UGS told the Board.

PRRB: Intermediary's Actions 'Troubling'

The Board upheld the intermediary's adjustments, citing that the adjustment was made on correct claims data.

However, "there may have been a process available to the Provider at the time the billing error was discovered of which the Provider was not notified," the PRRB says in the decision. "The Board finds the Intermediary's failure to properly inform the Provider of other remedies available troubling."

Nevertheless, "the Board has no jurisdiction over claims processing and, therefore, it has no authority to apply any of these remedies," it admitted.

Lesson learned: "A provider should never rely entirely on an intermediary to give the provider correct information as to its appeal rights or other remedies," warns attorney Joel Hamme with Powers Pyles Sutter & Verville in Washington, DC. "Anything the intermediary does on that score--including saying there are no remedies--should be checked and verified," Hamme urges.

"Don't rely solely on the advice of the intermediary," agrees Lanzafame, who represented Allegany in the case. The agency tried working through the problem with the intermediary but didn't receive the proper help, he tells Eli.

Another lesson: Agencies should realize they can't cure billing problems with the cost report, Hamme says. The claims data in the PS&R has to match the cost report data, so agencies must correct their claims if there are errors.

And under PPS, there's usually little to no money tied to cost reports anymore, experts note.

Allegany isn't likely to appeal the decision to federal court considering the dollar amount involved, Lanzafame says.