This week, National Government Services (NGS) conducted a home health advisory meeting in the Centers for Medicare and Medicaid Services (CMS ) Region V office in Chicago for the State Associations in CMS Regions II, V, IX and X. During the meeting, NGS staff provided updates on the following issues: New Medicare Administrative Contractor (MAC) awards and appeal process Home health utilization data from July to December 2008 Completed and remaining fiscal year (FY) 2009 home health education Recent Request for Anticipated Payment (RAP) issue causing overpayments Recovery Audit Contractor (RAC) New educational job aids to assist home health agencies New clinical education material Top reason codes for claim denials, rejections and returns to providers The following is a summary of each of the updates from the meeting. New Medicare Administrative Contractor (MAC) Awards and Appeal Process Section 911 of the Medicare Modernization Act of 2003 mandated that the U.S. Department of Health and Human Services (HHS) replace the current contracting authority to administer the Medicare Part A and Part B fee-forservice (FFS) programs (including home health) with a new MAC authority. This resulted in CMS initiating a Request for Proposal (RFP) process in 2007/2008 for new MACs. In January 2009, CMS announced four new contracts to process home health Medicare claims. One of the new home health contractors was North Dakota-based Noridian Administrative Services, LLC (NAS) who was awarded the five-year contract to provide administrative services for Medicare Part A/B home health claims in Jurisdiction 6, which encompasses the following states currently being served by NGS: New York, New Jersey, Michigan and Wisconsin. CMS had later debriefed NGS on why NGS was not selected. NGS subsequently decided to file a protest which was accepted by CMS. For the past three months, NGS appeal has been reviewed by HHS Government Accountability Office (GAO) who was given the responsibility for reviewing all MAC protests. NGS HCA protest was pleased was accepted, that NGS since protest Noridian was accepted, (NAS) since currently Noridian only (NAS) processes currently Medicare only processes Part A and Medicare B claims Part in the A upper and B Northwest claims in the and upper does Northwest not have any and Medicare does not have home any health Medicare claims home experience. health claims experience. During our meeting, A.J. Hanna, NGS Director of Provider Education and Outreach, stated that recent discussions with CMS and the GAO have resulted in NGS agreeing to drop its official protest of Nordian being awarded the Jurisdiction 6 contract but that the GAO will recommend (in the coming weeks) that CMS re-open the RFP process for this jurisdiction based on a variety of factors that CMS may not have fully considered when they awarded the Jurisdiction 6 home health contract to Nordian in January. NGS has indicated that it that will they keep our will State be Association releasing Advisory more information, group informed particularly regarding any formal announcement from CMS that the Jurisdiction 6 MAC Reform process has been re-opened. If and when this announcement happens, it means that a final decision as to which contractor has been awarded the Jurisdiction 6 contract will likely not occur until much later in 2009. If Nordian were to be re-awarded the Jurisdiction 6 contract, any type of contractor transition would most likely occur sometime in 2010. CMS had originally indicated that its goal was to have all of the new contractors implement processes to assume full responsibility for claims processing by March 2010, but that date has been pushed back to October 2011. Home Health Utilization Data & Medical Review NGS Medical Director, Dr. James Cope (Regions II, V, IX and X), provided the top five Medicare diagnoses in each state as well as other Medicare home health utilization data from July to December 2008. The top five diagnoses per Medicare home health claim in New York were:
Encounter Procedure/Aftercare V58 Orthopedic Aftercare V54 Diabetes Mellitus 250 Rehabilitation Procedure V57 Heart Failure 428 According to NGS data (July to December 2008), home health agencies in New York made 21.82 visits per episode, which was significantly higher than all of the other 16 states in Regions II, V, IX, and X. NGS data also revealed that Medicare beneficiaries in New York average 1.54 episodes (per beneficiary) which was slightly above average in comparison to the 16 other NGS states, and home health agencies in New York experienced a low utilization payment adjustment in 17.66% of their Medicare cases, which was about average in relation to the 16 other NGS states. FY 2009 Education Schedule NGS Christa O Neill, from Provider Education, provided an update on the home health education schedule for FY 2009 (October 1, 2008 through September 30, 2009) and stated that NGS decision to consolidate all of its regional Home Health Intermediary (RHHI) trainings worked well since it allowed any home care agency in NGS current workload to participate in past and upcoming home health education sessions. Ms. O Neill gave the following update on session participation: October 22, 2008 Home Health Demand Billing Session 143 attendees November 6, 2008 Home Health Ask The Contractor Session 106 attendees January 8, 2009 Home Health Billing Session 88 attendees February 12, 2009 Home Health Billing Session 140 attendees March 25, 2009 Top Ten Reason Codes Claims Were Denied Session 104 attendees May 7, 2009 Home Health Billing Session 280 attendees NGS has also scheduled the following home health and hospice teleconferences for FY 2009: July 2009 (exact date to be determined) Home Health Coverage / Clinical Session September 4, 2009 Home Health Billing September 17, 2009 Top Ten Reason Codes Claims were Denied Registration will be required through the NGS website at http://www.ngsmedicare.com/ngsmedicare/homepage.aspx for each of these training sessions; however, NGS will not open the registration until four to six weeks prior to each date and the registration section of their new website is still under development. The training material for each of these sessions will be posted on the NGS website two days prior to each session. Providers who have registered will receive an e-mail two business days prior to each session instructing how to download the training materials for the sessions. Recent Request for Anticipated Payment (RAP) Issue Causing Overpayments Ms. Christa O Neill announced that NGS has resolved the issue of some home health agencies experiencing RAPs and Medicare claims getting stuck in Status Location PB9996, resulting in an overpayment. According to Ms. O Neill, the fix to prevent this problem from occurring in the future was installed on April 6, 2009. From this date on, providers should no longer experience this issue on newly submitted or cancelled claims. NGS implemented a two-step process in the Fiscal Intermediary Standard System (FISS) to correct (and pay correctly) this issue for claims submitted prior to April 6, 2009. All affected RAPs and claims held up in FISS have been processed. However, NGS has identified a new issue that some providers may experience on auto cancelled RAPs. According to
However, NGS has identified a new issue that some providers may experience on auto cancelled RAPs. According to Ms. O Neill, some auto cancelled RAPs (bill type 3X8) submitted after the April 6, 2009 fix remain suspended in Status Location SM95HG. This is due to the system assigning an incomplete document control number (DCN). NGS has not yet set a date to fix this error; however, until a fix is implemented in the system, these claims will be worked on periodically so the cancels may process. There is no provider action needed to help adjudicate these suspended auto cancels. Recovery Audit Contractor According to NGS, CMS has announced the Recovery Audit Contractors (RACs) for all jurisdictions. The RAC Contractor in Region A (which covers New York, Vermont, New Hampshire, Maine, Massachusetts, Rhode Island, Connecticut, New Jersey, Delaware, Maryland, Washington D.C. and Pennsylvania) is Diversified Collection Services (DCS) who can be reached at 1-866-201-0580. Providers will be notified of a RAC audit/review when the RAC requests records. The provider will have 55 calendar days to respond to the medical record request. Providers have the right to appeal a RAC s decision by following the regular appeal process through their RHHI or MAC. CMS has the most current RAC information on its website, www.cms.hhs.gov/rac. Additionally, each RAC will have its individual website available no later than 2010. Providers will be able to monitor the status of claims requested for review on the RAC website. Providers are encouraged to visit CMS' RAC webpage to obtain updated RAC information. NGS Educational Job Aids NGS Christa O Neill reviewed the following two new job aids that were recently created by NGS staff to assist home health agencies billers: Billing the Home Health Request for Anticipated Payment (RAP) provides assistance for home health agency billers to successfully submit a RAP; and Billing the Home Health Claim provides assistance for home health agency billers to successfully submit a final Medicare claim. NGS is gathering feedback from home health agencies billers before posting these job aids to its website (www.ngsmedicare.com). HCA providers interested in having their billing staff review these job aids should send an e-mail to pconole@hcanys.org. Ms. O Neill then informed meeting participants that at our next advisory meeting she hopes to share some new job aids on the top five to ten reason codes for which claims are denied, returned to provider, or rejected on Medicare Secondary Payor (MSP) as well as Periodic Episode Payment (PEP) scenarios. Ms. O Neill then reminded participants that the following job aids have been posted to the NGS website: Counting 60-day Episodes in 2009 includes the 60-day end of episode date for each day in 2009. Timely Claims Filing outlines when claims with certain dates of services must be submitted by. Flowchart for Erroneous Episodes provides assistance in cases when claims were denied, rejected or returned to provider. RAPs provides background information on payment and frequent problems associated with the four types of RAP submissions.
RAPs provides background information on payment and frequent problems associated with the four types of RAP submissions. Beneficiary Transfer Situation includes instructions for initial and receiving home health agencies when a beneficiary elects to transfer from one agency to another. Additional Development Requests (ADRs) assists agencies with the process of ADRs that have been generated by NGS when they cannot make a coverage or coding determination from the information that has been provided on a Medicare claim. New Clinical Education Material Sally Rosiello, NGS Nurse Consultant, asked for participant feedback on a detailed draft presentation on Medicare Coverage of Home Care Services. The following were the significant learning objectives for provider participants, as described by Ms. Rosiello s presentation: To understand the Comprehensive Error Rate Testing (CERT) and Progressive Corrective Action (PCA) processes includes reasons why some agencies receive medical review prepay probe reviews; To understand the RAC includes information on the RAC contractors as well as common payment errors; To review Medicare coverage guidelines for skilled nursing and therapy services in home care includes real life scenarios/examples of Medicare home health cases with an opportunity for discussion on what Medicare would cover; To understand documentation necessary to demonstrate medical necessity includes information needed in the plan of care as well as recommendation when submitting nursing and therapy documentation; and To understand common denial reasons includes the top reasons claims are denied. Throughout the presentation HCA and other state association representatives made many comments and suggestions which Ms. Rosiello plans to incorporate into the final presentation. HCA will notify members when NGS begins offering this presentation to providers. Top Five Reason Codes for Claim Returned to Providers (RTP), Denied and Rejected NGS did not have an updated list of the top five reason codes for home health claims being RTP d, denied and/or rejected. At a our previous advisory meeting, Ms. O Neill provided the following top five reason codes for which claims were returned to the provider (RTP), denied or rejected for the NGS Wisconsin workload (includes New York) from the last quarter of 2008. (Ms. O Neill hopes to be able to provide updated information from the first quarter of 2009 at our next meeting.) The top five reasons for claims being RTP d in the Wisconsin workload (September to December 2008) were: Code 38107 a RAP must be submitted before a home health final claim can be submitted. Code 31147 claim does not include the appropriate supply revenue code. Code U5381 a RAP or home health claim overlaps an existing episode with a different provider number and source of admission B or C is not present. Code U538G A RAP or home health claim overlaps an existing episode with the same provider number and the from date is different than the episode s start date. Code U538F A RAP or home health claim overlaps an existing episode with the same provider number and the from date equals the episode s start date.
The top five reasons for claims being RTP d in the Wisconsin workload (September to December 2008) were: Code 38107 a RAP must be submitted before a home health final claim can be submitted. Code 31147 claim does not include the appropriate supply revenue code. Code U5381 a RAP or home health claim overlaps an existing episode with a different provider number and source of admission B or C is not present. Code U538G A RAP or home health claim overlaps an existing episode with the same provider number and the from date is different than the episode s start date. Code U538F A RAP or home health claim overlaps an existing episode with the same provider number and the from date equals the episode s start date. The top five reasons claims were denied in the Wisconsin workload were: Code 56900 claim denied due to provider failure to submit documentation requested by the intermediary within 45 days. Code 55H4D claim denied because medical documentation submitted to the intermediary did not show that the therapy services a beneficiary received were reasonable and necessary. Code 55H3A claim denied due to lack of skilled observation. Code 55H2B claim denied because homebound requirement is not met. Code 39928 claim denied due to each line of charges on the claim has been denied by NGS Medical Review. Finally, the top five reasons claims were rejected in the Wisconsin workload were: Code 38200 is an exact duplicate of a previously submitted claim and has many of the same fields from the previous claim. Code 38157 RAP and final claim were submitted at the same time. To avoid this problem, wait to submit your final claim until the RAP has been finalized. Code U5233 the services on this claim fall within or overlap a Medicare Advantage (MA) HMO enrollment period. Code C7080 the dates of services on this claim fall within or overlap the from and through dates on an inpatient claim from another provider. Code 38055 claim was submitted as a Medicare primary claim and contains exact services dates corresponding to a previously submitted claim for the same provider with at least one matching revenue code. Next Meeting NGS next Home Health Advisory Meeting for State Association representatives is tentatively scheduled for September 14, 2009. HCA will provide a detailed Policy Memorandum to the membership after that meeting. HCA will also provide updates via our newsletter on any news related to NGS, including any formal announcement Summary provided by Home Care Association of New York State