CMS Hospice Update on Incorrect Payments Identified for the Two Tier Payment and SIA Payments
August 2, 2016 02:32 PM
At the July Home Health, Hospice and DME Open Door Forumthere was discussion of ongoing claims processing issues related to the new two-tiered payment system for Routine Home Care (RHC) and the Service Intensity Add-on (SIA) for visits at the end of life. Centers for Medicare & Medicaid Services (CMS) staff identified three issues that are affecting hospice payments for RHC and the SIA, and indicated they would provide written descriptions of the issues for hospice providers and other interested parties. The following information, containing the known issues and timeframes for correction of these issues, has been extracted from a notice issued by National Government Services (NGS) but is applicable to all hospices. We anticipate that the other Medicare Administrative Contractors (MACs) – CGS and Palmetto – will release similar information in the near future.
Two Tier Routine Home Care Payments
Issue: Thetwo tier payment rate is not being applied appropriately to claims submitted on or after January 1, 2016. In some instances the Medicare system is incorrectly paying at a low rate, instead of the high rate. This system action is causing an underpayment to providers. The Medicare system was updated with a “fix” on July 25, 2016 to resolve the issue.
Provider Action: There is no provider action to be taken.
Issue: An issue has been identified with the two tier payment rate not being applied appropriately to claims submitted on or after January 1, 2016. In some instances the Medicare system is incorrectly paying the RHC at a high rate, when the low rate is appropriate. The Medicare system is checking a single prior benefit period and not all benefit periods that are not separated by 60 days. This inappropriate processing is causing an overpayment to providers. CMS is aware of the issue and the MACs anticipate instructions from CMS in the January 2017 release to correct the Medicare system issue.
Provider Action:At this time there is no provider action to be taken. Providers should not report this overpayment on their credit balance reports.
Service Intensity Add-On (SIA) Payment
Issue: In certain situations, the Medicare system is not applying the end-of-life (EOL) service intensity add-on (SIA) payment to the previous month’s claim, when a patient dies within the first few days of a month. The Medicare system is designed to trigger an automatic adjustment of the prior month’s claim if the prior month’s claim is eligible for the SIA payment. This adjustment will apply the EOL SIA amounts to the previous claim that could not be identified in the initial processing. These adjustments are not occurring on the prior months claim in the following situations:
When the incoming claim does not contain a qualifying RHC service;
When the provider adjusts the original claim to add qualifying (or additional) RN and/or MSW visits;
When the provider adjusts the IUR (32G) claim that originally applied the SIA payment, the adjustment claim removes all EOL SIA payments.
CMS is aware of the issue and the MACs anticipate instructions from CMS in the January 2017 release to correct the Medicare system issue.
Provider Action: Currently there is no provider action to be taken. Providers do not need to submit an adjustment claim for the previous month, nor does the provider need to submit an appeal. This is a Medicare system issue.