Managed Care:
PEP YOURSELF WHEN BENEFICIARY GOES TO MANAGED CARE
Published on Mon May 15, 2006
More MA adjustments are coming up.
Home health agencies facing the thorny issue of billing when a Medicare beneficiary elects a managed care plan may benefit from some recent advice from the feds.
If you know a patient has transferred to a Medicare Advantage plan, you should bill using status code 06, a Centers for Medicare & Medicaid Services staffer directed in the May 24 Open Door Forum for home care providers. Otherwise the Medicare claims system will return your claim and you'll have to waste time and resources correcting it.
Remember: Status code 06 directs the system to apply a partial episode payment (PEP) adjustment to the amount claimed.
If Medicare pays you for a full episode and then an MA enrollment is recorded in the system for the same time period, the system will go back and automatically PEP the episode amount based on the date the beneficiary enrolled in the MA plan, CMS explained. MA Enrollment Information Wrong And you may see more of these PEPs in the near future, CMS warns in a MLN Matters article on the topic (SE0638) released May 31. "A variety of CMS system issues" kept the agency from synchronizing its MA enrollment and disenrollment information until recently, the article says.
Over the next six months, intermediaries will adjust fee-for-service claims that were erroneously paid when the patient was under an MA plan, the article explains. Adjusted claims' remittance advices (RAs) will list Reason Code 24--"Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan." Providers then should contact the MA plan for payment, CMS directs.
You may have more luck getting your MA claims paid than you have in the past. When CMS reverses FFS payments due to "confirmed retroactive enrollment in an MA plan," the provider must bill the plan. Then the plan must pay its usual rate if the provider is part of the MA network, the article says.
The plan must pay the FFS rate if the provider isn't part of the network, CMS says. And the provider can bill the beneficiary if the plan denies payment altogether.
Because of the system problems, providers also may have seen claims denied for patients that weren't really enrolled in an MA plan. Providers should resubmit those claims now, CMS instructs.
CMS says about 386,000 claims for 100,000 beneficiaries are affected by the adjustments, but it has not specified how many are home care claims, according to the National Association for Home Care & Hospice. NAHC is seeking clarification on a number of issues surrounding this new policy, it says.
Know Your OASIS MA Ropes In the forum, CMS also reminded listeners of OASIS requirements related to Medicare managed care. Medicare doesn't require agencies to discharge and conduct [...]
