Medicare Compliance & Reimbursement

Inaccuracies in the CWF jeopardize your Medicare pay.

Home health or hospice providers who depend on the Common Working File to reflect the patient's history could be risking their Medicare reimbursement, since CMS officials claim that their hands are tied by the statutory language.

CMS officials pointed this out in the May 23 Open Door Forum for home health, hospice and durable medical equipment providers. When you admit a home health or hospice patient or furnish DME or supplies to a patient and her CWF history comes up clear, that won't necessarily mean you're entitled to the Medicare payment you think you'll be receiving.

Why: When another home health or hospice provider serving the patient doesn't bill promptly, the CWF won't show that the patient is under a home health or hospice plan of care, noted CMS's Katie Lucas in the forum. So you'll bill for the reimbursement you believe you're entitled to, then have the claim shot down or have reimbursement taken back when those late-billed claims show up in CWF.

Hospices check the CWF for notices of election (NOEs) and claims, one provider told CMS. When NOEs and claims turn up later, the current hospice's benefit period is no longer correct, and certification and face-to-face dates are no longer timely, the hospice complained.

CMS's hands are tied when this happens, Lucas related. For any reason, if the F2F encounter didn't occur, the certification isn't complete and the episode isn't covered. "While we share your frustration about providers who are slow to post their notice of elections, we are limited by the statutory language in what we can do to address this issue." she said.

For DME suppliers, they'll submit a claim for supplies and get paid, then see that reimbursement recouped six or nine months later when a Home Health Agency finally gets around to billing for the patient, a supplier told CMS in the forum.

"We're really restricted, similar to the hospice situation, for home health and statutorily we're required to bundle all the supplies into the home health PPS payment," CMS's Randy Throndset told the caller. "Unfortunately CMS doesn't have any flexibility with regards to that because of what the statute tells us we have to include in our payments."

HHAs tend to run into duplicate billing trouble when another agency is providing services at the same time. Home Health & Hospice Medicare Administrative Contractors have set up procedures for dealing with these disputes, to determine who has the right to bill Medicare.

For example: When settling such a dispute, HHH MAC CGS checks the patient record to see whether the HHA printed a screen shot of the ELGA/ELGH screen. It also requires the HHA to contact the other agency at least three times before stepping in. See CGS's other requirements online at www.cgsmedicare.com/hhh/education/materials/hh_transfer.html.

Play Detective During Admission

Don't rely solely on the CWF for your patient's history, Throndset urged forum participants. "There are different avenues besides just looking at the CWF systems," he said.

Talk with the patient and/or her representatives to find out what services she has received, Lucas advised. Document those conversations, she added.

CGS encourages HHAs to include information in their admission paperwork, explaining that only one agency can be in the home during an episode of care, and any other agency won't get paid. "This documentation is important if a dispute occurs," the MAC says.

Plus: Bill timely yourself, so other providers know what they are dealing with, CMS urges providers.