Medicare Compliance & Reimbursement

Home health agencies have received another reprieve from the recoupments of tens of thousands of dollars, this time while industry representatives plead their case to Medicare.

The Centers for Medicare & Medicaid Services had informed HHAs that recoupment for partial episode payment (PEP) adjustments would begin May 5. The claims processing system had failed to make PEP adjustments since the beginning of the prospective payment system in October 2000, and CMS planned to take back the money incorrectly paid for episodes that should have been PEP'd.

But CMS sent out a May 2 message informing providers that "this project has been temporarily delayed and recoveries will not begin on that date."

This time it's not claims system glitches that have held up the process, says a CMS official. "The delay is the result of a request from the national [home health] industry associations to discuss the recoupment process," the source says. "We couldn't arrange a meeting before our planned start date ... so we decided to hold off until after the meeting is held."

While the delay might give HHAs a break in the short run, it's a problem in the long run, predicts Burtonsville, MD-based attorney Elizabeth Hogue. "The longer the period of time before recoupment, the bigger liabilities agencies are likely to have," she cautions. "Some agencies are likely in for big surprises at some point in the future."

HHAs that thought they were done with big recoupment surprises when PPS replaced cost-based reimbursement have been sorely mistaken. "Now it just seems like the same old story all over again," Hogue laments. Agencies have "potential liabilities hanging out there with no real way to grab hold of them, quantify them or plan for them."

Members of the Visiting Nurse Associations of America have reported numerous problems with the PEP recoupments, reports the VNAA's Bob Wardwell.

VNAs served by regional home health intermediary Associated Hospital Service of Maine got a look at their PEPs before the start date when the adjustments were accidentally made all at once. The RHHI is reversing the recoupments so they can be made gradually, a week at a time, with the other RHHIs' adjustments.

One VNAA member found a PEP for a patient who didn't have another stay afterward that would have caused the adjustment, Ward-well relates.

Other members have patients who were admitted to a second agency, but then discharged back to the first agency when the second agency found out about the patient's existing episode. The second agency has renounced its claim to the patient, but the first agency still is PEP'd due to the claim filed.

The thorniest issue is when the two agencies dispute the right to bill for a patient, Ward-well worries.

At least one RHHI, Palmetto GBA, says it requires agencies that accept transfer patients to have documentation proving they checked the HIQH for an open home health episode, informed the patient of her rights and responsibilities in transfer, and if an open episode existed, informed the first agency of the transfer. If HHAs don't do this, they don't have a right to bill for that transfer patient, Palmetto has said.

CMS needs to standardize requirements like this and prepare RHHIs to adjudicate the transfer cases that might arise from the PEP takebacks, Wardwell maintains.

In its meeting with CMS, the National Association for Home Care & Hospice plans to bring up two main issues, says NAHC's Mary St. Pierre. First, providers want more information and input on the methodology for the recoupments.

Second, NAHC plans to ask CMS to consider limiting how far back the recoupments reach. "CMS is asking agencies to repay money they received two-and-a-half years ago" in some cases, St. Pierre protests. HHAs generally have had no idea they had liability for these PEP adjustments the system failed to make.

Even if industry reps succeed in winning a break from some of the adjustments, HHAs likely still will have PEP recoupments on the horizon. CMS said in the message that it will inform providers of a new initiation date for the PEP takebacks "in the near future."