Home Health & Hospice Week

Hospice pay reform billing headache drags on.

The news that you’ll likely have to adjust your own claims that Medicare paid incorrectly is not sitting well with hospices fatigued by months upon months of reimbursement errors.

After hospice payment reform took effect in January 2016, the Medicare claims system paid claims incorrectly due to a number of glitches — most of which revolved around paying the high-versus-low Routine Home Care rate that splits at 60 days, and the Service Intensity Add-on payments for visits in the last five days of life.

The Centers for Medicare & Medicaid Services had thought it finally cleared up all those RHC-related payment errors, and said so in its Feb. 8 Open Door Forum for home care and hospice providers (see Eli’s HCW, Vol. XXVI, No. 7). But now it’s walking that message back.

“We’ve since learned that in some cases, Medicare systems are still miscounting RHC days,” a CMS official said in the agency’s March 22 forum.

“These cases are limited to situations where there is a prior hospice benefit period that must be included in the count.”

Do this now: “Hospices that are aware of Routine Home Care counting errors related to prior benefit periods should withhold adjustments until further notice,” the staffer said. “We are unsure when a fix will be scheduled for these ongoing issues.”

One hospice caller voiced her frustration with this ongoing issue. “When there was a proposed rule for the hospice payment reform, our hospice along with many others suggested that CMS test some of this so that we could avoid the very thing that we’re experiencing now,” she told CMS. “CMS insisted on proceeding without testing, and here it is this much later and we still have these     problems.”

“You’re absolutely right to be frustrated; I am too,” another CMS official responded. However, CMS did perform testing before the new payment system took effect, identified errors and fixed them before the new payment methodology went live, he pointed out. It’s just that more errors that didn’t turn up in testing have plagued hospice billing.

Part of the problem is that different HHH Medicare Administrative Contractors tell providers different things about the status of glitch fixes and what they should be doing, the caller said.

That may arise because the nature of the problems still dogging the system haven’t been pinpointed, the CMS staffer suggested. CMS and the three MACs will get together once those issues are resolved to deliver a consistent message, he pledged. “When we know what we need to say, we will say it.”

Mass Adjustments Won’t Work

Another problem is fixing claims for SIA underpayments. One hospice caller asked when to expect a mass adjustment for those. “We still have some balances that are hanging way out from last year,” she told CMS.

In the last forum, CMS said it was trying to find accurate criteria for identifying claims for mass adjustment. “To date, we have not been successful,” the CMS source said.

The upshot: “I don’t believe we’ll be able to mass adjust them,” the staffer revealed. Providers will have to ID and adjust such claims themselves.

The provider was indignant about the extra burden this will place on hospices. “That’s something Medicare is supposed to be adjusting,” the caller insisted. “Why are providers being told to adjust claims when these issues are things that happen by the Medicare system?”

The problem is that the system can’t ID which claims need adjusting, so MACs would have to reprocess all hospice claims since payment reform began, the official explained. “We would end up mass adjusting thousands of claims that didn’t need to be touched in order to identify the ones that needed to be,” he said. “We think that will be more disruptive to providers’ accounts receivable and processes ... than having providers submit adjustments for the claims that they know … are incorrect.”

The good news: At least most of the payment errors are fixed and “for the most part, claims are paying correctly,” observes billing expert M. Aaron Little with BKD in Springfield, Mo.

The bad news: “The claims that initially didn’t pay correctly in 2016 are … a nagging concern,” Little tells Eli. “They aren’t so much of an ongoing headache but more of a lingering migraine that doesn’t fully fade.” The dollar amounts per claim are likely not significant, but there may be many claims that add up to a substantial amount.

Problem: For hospices following CMS’s instructions, adjusting claims themselves “will be a very big pain due to the likely high number of claims,” Little predicts.

Bigger problem: And even more concerning is that many providers may lack good records to easily go back and identify which claims paid with errors, Little expects. “So far the software vendors are getting better at calculating the two RHC rates and SIA payments, but back at the time the vendors were struggling just like CMS. So, many providers may not have great records to know which claims were incorrectly paid.”

Meanwhile, hospices don’t need to worry about filing deadlines for claims that need adjustments. “We recognize some of these … may be approaching or already beyond the timely limit filing date for adjustments to take place,” the CMS source acknowledged in the forum. CMS will instruct MACs to override that deadline to make adjustments.