Eli's Hospice Insider

Published on Tue Dec 22, 2015 PDF

Ring in the New Year with tighter billing oversight.

If you’re not paying attention to billing details in 2016, you could be costing yourself significant reimbursement and not even know it.

Under hospice payment reform finalized in the 2016 payment rule, Medicare will pay hospices routine home care rates in two tiers: higher payment ($186.84) for days 1-60, and lower payment ($146.83) for days 61 and higher. That compares to the current RHC rate of $161.89 regardless of length of stay.

Medicare will also pay a Service Intensity Add-on on top of the RHC rate when hospices furnish RN and social work visits in the last seven days of life. Medicare will make SIA payments in 15-minute increments up to four hours per day at the Continuous Home Care hourly rate, which is $39.37 for 2016.

Good: The Centers for Medicare & Medicaid Services has confirmed that the Medicare claims system will automatically award the SIA payments when the relevant visits occur in the last seven days of life. Hospices don’t have to do anything extra to claim the SIA payments. That’s true even when the SIA time period spans two claims, a CMS official said in the last Open Door Forum for hospice providers.

Bad: If your SIA-qualifying visits don’t make it onto your claims, you won’t receive the reimbursement you’re entitled to — and you may not even realize it because you didn’t expressly bill for those SIA visits.

“If visits are incorrectly coded, it could … result in claim underpayments since the SIA is to be paid when claims are billed indicating the occurrence of visits in the last seven days of life,” cautions billing expert M. Aaron Little with BKD in Springfield, Mo.

Underpayments may be more damaging to hospices than before, considering the reduced RHC rate under hospice payment reform, notes Rose Kimball, owner of billing company Med-Care Administrative Services in Dallas. Even with the SIA payment, “this Add-On may not be sufficient to offset care reimbursed at the lower base rate (services after the 60th day),” Kimball tells Eli.

When the new payment system hits Jan. 1, hospices must be diligent in making sure their claims are accurate and they obtain the reimbursement they deserve, experts advise (see related story, p. 1).

Note: See the 2016 final rule at www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf and an MLN Matters article about the billing changes at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9201.pdf.