Eli's Hospice Insider

Potential headache: Hospices must wait on MA submissions for payment when patients disenroll.

You can’t count on that payment for a patient enrolled in a Medicare Advantage VBID plan to stay yours forever, according to new Medicare Administrative Contractor guidance. A newly posted question-and-answer from a recent Palmetto GBA Hospice Coalition meeting shows why.

Background: “We have a handful of patients who have active Value-Based Insurance Design (VBID) coverage, but Palmetto GBA paid the claim. The patient admitted to hospice in 2022 and the Medicare Advantage (MA) Contract and Plan number is listed on the 2022 VBID payer listing. We tried to submit an 817 with code D9 and comments directing Palmetto GBA to recoup their payment due to the patient having active VBID coverage but the claim was just repaid,” one hospice told the coalition.

Question 1: What actions should providers take to resolve? Is this a problem on Palmetto GBA’s end, or the VBID payer not reporting VBID coverage to Palmetto GBA correctly?

Answer 1: Palmetto GBA processes claims by the VBID MAO (MA Organization) enrollment information loaded on the [Common Working File]. If the MAO information is not correct in CWF, the MAC would pay the claim. If the MAO is loaded correctly, the claim would reject with Reason Code U523A (Narrative: The dates of service are during both a hospice election period and a MA plan’s period that is in a VBID Model).

Hospices seeing this issue should reach out to the VBID Model Team with any questions, comments, or concerns about the Hospice Benefit Component at VBID@cms.hhs.gov. Palmetto GBA has sent this question to this email address and is awaiting a response.

Question 2: Should these overpayments be listed on our Quarterly Credit Balance reports?

Answer 2: No. When the CWF record is corrected, the claims should be adjusted and rejected, taking back the payment. System issue should never be reported on CBRs.