Prospective Payment System:
YOU'RE OFF THE HOOK FOR SOME BUNDLED ITEMS
Published on Mon Jul 25, 2005
CMS' new explanation of HHA consolidated billing could help your bottom line.
When rehab providers come knocking on your door for payment after their Medicare claims deny due to bundling, don't be so fast to reach for your wallet.
That's the message of a new transmittal ex-plaining home health consolidated billing from the Centers for Medicare & Medicaid Services. The primary home health agency is responsible for providing bundled services, which include outpatient therapy and supplies, either directly or under arrangement, CMS makes clear in Aug. 5 Transmittal No. 635 (CR 3948).
"However, providing services either directly or under arrangement requires knowledge of the services provided during the episode," CMS continues. "An HHA would not be responsible for payment to another provider in the situation in which they have no prior knowledge (e.g., they are unaware of physicians orders) of the services provided by that provider during an episode."
How it works: Outpatient therapy providers - including hospital departments - and suppliers come looking for payment when Medicare denies their claims due to bundling. If the HHA has filed a request for anticipated payment (RAP) before the other provider or supplier submits its claim, the claim gets denied with Reason Code B15 on the remittance advice: "Payment adjusted because this procedure/ service is not paid separately." The RA also includes Remark Code N70: "Home health consolidated billing and payment applies."
If the other provider submits its claim first and then a RAP comes in for the patient, the intermediary or carrier makes a post-payment denial of the claim and recoups the money from the other provider, CMS explains in the transmittal. Bundling Chronically Misunderstood PPS regulations have always made clear that HHAs don't have to pay for services under arrangement if they didn't know about them ahead of time, says consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. But agencies continue to receive requests for such payments, even five years into PPS.
Bundling "is still one of the most misunderstood components of PPS," notes Abilene, TX-based consultant Bobby Dusek. This transmittal, which finally puts five years of CMS instructions on this topic into the manual, "will help," Dusek predicts.
CMS put together the transmittal due to "some questions from both HHAs and other provider types," a CMS official tells Eli. But the staffer maintains there's been no increase of questions driving the issuance. "It's just a longstanding item from our to-do list that we had an opportunity to get done," the source notes. To Pay or Not To Pay HHAs tend to see a problem with bundling outpatient therapy the most, notes the National Association for Home Care & Hospice.
"Too frequently, patients either seek out, or physicians refer patients to, outpatient services that are [...]
