Home Health Guidelines: Get a Thorough Update on NRS Claims Processing Edits

There have been many claims processing errors since PPS refinement was implemented in January 2008. And quite honestly we could probably sit here and make a laundry list of those errors. Get the expert home health training in claims processing edits in this article.

Some of those have been resolved in the sense that maybe only a handful if any of your claims would have had an incorrect payment while other providers have had numerous errors due to just, you know, one or two issues that where the claims processing edits have not functioned properly.

And so, to date, those errors within the Medicare claims processing system have created not just overpayments to you but also under payments. So it really is a variety. It's not any one issue that has probably been significant, it's been multiple issues.

So as of today, our expert says in a home health conference, there's been a lot of claims processing edit corrections that had been implemented so that the issue there with those six is this not so much that it has – these fixes have gone back and reprocessed claims to make corrections. But it has prevented continuing claims processing errors.

So at this point, those overpayments and underpayments that have been created from the claims processing errors, at this time, there is no official word from CMS as to when those errors or rather those payment errors will be reprocessed so that either you can be – have your claim on that recouped or repaid depending on the situation.

May 24, 2018
Lynn M. Anderanin
May 31, 2018
Will Woodlee and Celeste Wheeler
Jun 7, 2018
Lynn M. Anderanin

Now, when it comes to troubleshooting these incorrect payments, it is very critical to investigate any payment received that varies from what was expected. So in order to do that, you really have to have very effective billing and payment tracking tools as well as processes. So hopefully you have a good piece of software or a spreadsheet or whatever it takes within your organization to be able to anticipate what you should have been paid so that when you do get paid, you have something to go back to and determine whether or not what you've received has been correct.

And certainly, any differences do need to be investigated and we really encourage you to do that at the time when the payment is being posted because it's very easy to think well. Too easy for other things to come up during the day to not allow time to go back and troubleshoot that. So we would really encourage you to make it something a part of your process to investigate immediately.

But really, you know, trying to pursue what these issues are or why it didn’t pay. That's the only way that you can ensure payment accuracy, again, you know, with all these errors that we've had since January has been very important to be able to identify, you know, what is this payment variance because it's something that happened with the claim that you filed meaning that maybe something didn’t get reported correctly or is it an actual billing error.

So, you know, again, in order to do this, the person that are in place to be able to track this really have to have good training on all of these relevant PPS issues which we just got again of short list here of certainly understand the payment groupings. And the difference between a grouping five versus a grouping three but also understanding the implications of episode timing and have that episode timing question on the CMS OASIS gets reflected into the HIPPS code and ultimately the payment.

As well as the therapy as therapy is such a significant component of the PPS refinement payment. It's very important to have a good solid understanding of how that affects your payment so that if you have a difference you can determine is it because we just didn’t bill all of our visits or perhaps the visit that were performed were significantly different than what was estimated.

But understanding the HIPPS code and the CMS OASIS matching string  is absolutely critical and if you are uncomfortable with some of the information, we are going to be spending some time on that in the coming slides.

But also payment adjustments. You know, with PPS refinements, we have essentially three basic formally recognized payment adjustments between, LUPAs, PEPs and outliers. But then we also have adjustments that are routine but not necessarily termed an official payment adjustment for episode timing and for therapy utilization.

So the point of that is there are number of issues that legitimately would cause you to be paid a different amount on your final claim than what was initially expected. So it's just important to be able to recognize when it is something that is legitimate versus something that is actually an error that at some point needs to be corrected.

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