Eli's Hospice Insider

It's up to you to seek your rightful reimbursement for payment errors under reform.

The clock is almost up for taking advantage of the streamlined procedures aimed at improving the messy correction process for payment errors under hospice payment reform, but the new procedure still leaves the situation confusing.

The problem: When hospice payment reform took effect in January 2016, the Medicare claims system paid some Routine Home Care and Service Intensity Add-on claims incorrectly. The Centers for Medicare & Medicaid Services acknowledged the errors fairly early on, but a system fix for the glitches wasn't implemented until May 2017. Hospices widely believed that CMS would automatically adjust the incorrectly paid claims when the fixes went in. Instead, CMS told hospices they had to adjust their own claims on a one-by-one basis, sparking indignant comments from hospices about Medicare shoving the workload for their errors onto providers (see Eli's Hospice Insider, Vol. 10, No. 8).

The solution: While CMS still says it's not feasible to automatically adjust hospice claims for the corrections, it has provided an easier way for hospices to submit their corrections. "All hospices seeking to correct their payments for RHC and SIA errors that are not related to transfers may submit a list instead of submitting individual adjustments," CMS says in MLN Matters article SE 17029. (See submission details, p. 83.)

Deadline: Hospices have until Oct. 20 to submit their lists. Then the MACs have until Jan. 19, 2018, to process the adjustments, CMS says.

Allowing the list for billing "is certainly easier than re-billing each affected claim individually," cheers Beth Noyce with Noyce Consulting in Salt Lake City.

"We applaud CMS for allowing the simplified process," says finance expert William T. Cuppett with The Health Group in Morgantown, West Virginia. "Hospices that have tracked, or have the ability to identify, the payment errors should find the schedule easier than the alternative."

Correction Process Downsides Persist

Hospices continue to have objections or, or at least questions about, the correction process for these incorrectly paid claims.

First is whether they even need to submit them. CMS indicated in a question-and-answer set earlier this year that "hospices that lack the information to identify the errors at this point cannot take any action."

"Many hospices have not been tracking incorrect payments in a manner that would facilitate an easy submission of claim errors. Many expected the MACs to fix the errors," Cuppett tells Eli. "Do hospices really not need to report billing errors if information was not tracked? Is this, in fact, voluntary?" he asks.

If reporting is really voluntary, hospices will need to assess whether they want to submit adjustments.

Information provided by the MACs indicates SIA underpayments and RHC overpayments, Cuppett says. "However, it appears that CMS and MACs believe that hospices have been overpaid generally."

Hospices that want to submit adjustments, but didn't track the errors, could have a big job ahead of them. "For those agencies that trusted CMS to pay as promised, and those who don't have a great process in place to track whether payment matches the amount expected on each claim, creating a list of incorrectly paid claims will be labor intensive," Noyce expects.

If hospices' electronic medical records systems don't track and report transfers between benefit periods, compiling the list of corrections may be difficult, notes consultant Cindy Gibbons with Simione Healthcare Consultants in Hamden, Connecticut.

But the good news is that SIA overpayments are "easy to see" on remittance advices, Gibbons says.

Could Adjustments Change Cap Liability?

For hospices that do want to go ahead with submitting adjustments, they need to pay attention to some issues. "In recent weeks, each MAC has worked with a volunteer hospice to develop an adjustment process and perform a trial run using a list of claims," the MLN Matters article says. But "experience with provider-submitted adjustments has ... shown that in many cases the adjustments are having no effect on payment. Actions that only the MAC can take are needed for the adjustments to process accurately."

In other words, hospices that have already been submitting adjustments individually may find the work is for naught.

If no pay change results from the adjustments the MAC makes, "the provider may need to do further research into the case to determine whether there had been a payment error," CMS says.

Other questions about the adjustment process linger, Cuppett adds. Hospices need to know how the adjustments affect their Provider Statistical & Review (PS&R) reports - and potential cap liability - and credit balance reports, he says.