Medicare Compliance & Reimbursement

After nearly three weeks under the revised prospective payment system, home health agencies (HHAs) are starting to see their Medicare claims pay.

Medicare installed the PPS software fixes Jan. 17, a Centers for Medicare & Medicaid Services (CMS) official says. The regional home health intermediaries (RHHIs) are releasing the held claims and those are processing toward payment, the source says.

Dates for those activities will vary by intermediary, the CMS staffer adds. RHHI Cahaba GBA released its held claims Jan. 17, it says in a message to providers. Intermediary Palmetto GBA did so on Jan. 18. National Government Services and Associated Hospital Service haven't said if or when they've released their held claims, although Bob Wardwell with the Visiting Nurse Associations of America reports that they have.

The previously reported problems with CBSA codes (error code 32038) and HIPPS codes straddling 2007 and 2008 appear to be "largely cleared up," cheers Baton Rouge, LA-based software company Lewis Computer Services on its Web site. "That part of the software update seems to have been successful."

The problem with treatment authorization codes (30720) is now editing correctly, Cahaba and Palmetto say. That means claims held up for that reason are probably due to software or other errors on the HHAs' end.

Requests for anticipated payments (RAPs) and claims are starting to process, agrees billing consultant Rose Kimball with Med-Care Administrative Services in Dallas.

"The money must be starting to flow," notes Wardwell, a former top CMS official who oversaw PPS' original implementation in 2000. "The complaint volume is diminished."

But it is taking time to resubmit returned claims and navigate some of the Direct Data Entry (DDE) format changes, Kimball laments.

Even when claims do pay, providers will have a tough time reconciling them with what should have been paid, Kimball expects.

A claim for a patient who had a fall mid-episode and begins therapy will see drastically different reimbursement than what was indicated on the RAP, Kimball notes. But under PPS revision rules, you still submit a final claim with the same HIPPS code and the system auto-adjusts it for the increased therapy. That bumps the episode into a whole new grouping step, HIPPS code and payment level that will be "drastically different," she says.

While the major problems that were holding nearly all 2008 RAPs for three weeks are now clearing up, there are still more payment system issues ahead.

The system is failing to auto-adjust certain episodes when needed, Cahaba warns in a Jan. 18 email to providers. The error occurs (1) when the first digit of the HIPPS code doesn't reflect the actual episode number or (2) when the first digit of the HIPPS code is a 5, indicating 20 or more therapy visits, but there are less than 20 visits on the claim. The latter scenario should trigger a downcode, but currently doesn't.

Another problem is that the system appears to be adding Non-Routine Supplies (NRS) payments onto 2007 episodes instead of just 2008 episodes, Cahaba explains.

"We are unable to identify the claims that are being inappropriately affected by the new issues," the intermediary says. "Therefore, home health claims are being allowed to continue processing."

Cahaba expects a software fix by the end of the month. "No action by providers is necessary at this time," the RHHI instructs. "When successful testing is complete and the system updates are implemented, we will update you ... with information about correcting the processed claims."

And CMS in December already identified two other software errors that could underpay you for wound items and certain diagnosis code combinations.

You'll have to find and fix your own claims that have these problems if you hope to obtain correct payment, CMS instructed last month.

But agencies can be glad that intermediaries are no longer holding 100 percent of 2008 RAPs due to the problems, Wardwell says. "There are a couple small glitches, but nothing that is earth-shattering," he says. "These are on the way to being fixed."

The good thing about the PPS crisis is that it is reminding some agencies to focus on billing, Lewis maintains on its Web site.

"In all of this trouble, thousands of people in executive management have been forced to learn how their billing and collection operations work," the vendor says. "With seven trouble-free years of billing, it was easy to
let their knowledge fade and their management participation wane."

Now execs don't have that luxury. "Over the past three weeks these managers have gotten an education in their company's current billing processes and many are once again making this critical part of their business a priority," Lewis observes.