Healthcare Provider Solutions

CMS announced this week that Medicare Administrative Contractors (MAC) will accept a list of claims to be adjusted for incorrect service intensity add-on (SIA) and incorrect routine home care (RHC) payments, where the error is not related to hospice beneficiary transfers.

History
The SIA and high/low RHC payment changes were effective in January 2016. CMS implemented software to automatically process the claims for these payment changes where hospices would not have to do anything differently in developing the claim. However, the processing was flawed and hospices have not been paid correctly. There were several causes of the errors and several fixes implemented in the claims processing system but these fixes did not correct all claims previously paid in error. Typically, CMS would conduct a mass adjustment to fix the claims, but this is not possible for these errors because there is no way for the system to identify which claims contain the errors. Unfortunately, not all hospices impacted by the incorrect payments can easily identify which claims need adjustment either. Those that can, though, have noted how tedious and time-consuming it is for them to go through the process of adjusting claims and requested a more streamlined process. This will be accomplished by allowing the MACs to accept the list of claims needing adjustment.

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, by October 20, 2017. The list should be an Excel spreadsheet format and contain the following information:

  • The document control numbers (DCNs) of the claims to be adjusted
  • The dates of service for each claim
  • Whether the error is related to RHC days or SIA amounts

To avoid MACs making multiple adjustments on the same claim, providers are advised to send only one list. The MAC will adjust the claims based on the information provided. If no payment change results from the adjustments, the provider may need to do further research into the case to determine whether there had been a payment error.

For claims needing adjusted and involving transfers in the benefit period, the hospices should apply a workaround, per previous CMS instructions. The hospice should enter the “Start Date 1” in the current benefit period as the admission date on their claim, rather than their own admission date. This will allow all the days in the period to be counted in the RHC payment calculation. To facilitate processing the adjustments, hospices should add special coding to their adjustment claims. Append condition code D9 and submit a message in the Remarks section. The message should read, “Adjust due to RHC errors SE17014.”

One suggestion that Healthcare Provider Solutions (HPS) would like to make is for the SIA is to review every monthly claim where the patient had a date of death in the first 6 days of the billing period (calendar month). The majority of payment errors occurred when the date of death was in the first 6 days of a given month and the system was to reopen the prior month claim to fully pay the SIA for the last 7 days of life and the system failed. HPS has developed a calculator for establishing what you should be paid in all hospice claim scenarios. Purchase today and for a discounted rate you will receive the 2018 update when released.

More information on the workaround for claims adjustments involving transfers and the submission of a list of claims needing adjustment, see MLN SE17014 and MLN SE17029.