Help- My Home Health bills aren’t correct! Why! Diane Cox M.S. 2012 Suncoast Solutions Users Conference Description Not sure if your Home Health Claims in Suncoast are correct? Does the Medicare payment differ from the AR in Suncoast? This class helps you understand how your claims are calculated in Suncoast so that you can identify if claims are incorrect or not. Objectives ¢ Identify three important maintenance areas in Suncoast that affect claim calculations ¢ List important dates that affect claims calculations ¢ Identify at least one way to reconcile differences in AR between Suncoast and Medicare payments So…what can go wrong with your home health claims? ¢ Billing and Service Rates not updated properly ¢ CBSA’s not updated properly ¢ Supply Adjustment Codes not updated properly ¢ Bill Errors ¢ Oasis Transmissions- Approvals and transmissions So…what can go wrong with your home health claims? (cont.) ¢ ¢ ¢ ¢ ¢ ¢ ¢ Pay source additions Pay Source changes PPS Adjustments F2F Encounters Therapy Threshold Assessments DME & Supply Maintenance Other Miscellaneous Reasons Billing and Service Rates ¢ Not updated timely ¢ Not updated properly l Can cause undesired adjustment claims 2013 PPS Rates- TBA Wage % should be 77.082 except PPS and LUPA Add-on ¢ HHAl ¢ 0421 G0151 0551 G0154 0441 G0153 Lupa addon- wage = 0.000 nwage= 0.000 Gross: ???? l ¢ G0152 STl ¢ 0431 RNl ¢ G0155 PTl ¢ 0561 OTl ¢ G0156 MSWl ¢ 0571 0551 G0154 PPS- Net= Gross= 0.00 l 0023 2013 PPS Rates- TBA Wage % should be 77.082 G-Codes ¢ OT Maintenance Visitl ¢ 0421 G0157 0551 G0164 0551 G0162 RN Observation & Assessment Visitl ¢ G0159 RN Evaluation & Management Visitl ¢ 0421 RN Education/Training Visitl ¢ G0158 PTA Visitl ¢ 0431 PT Maintenance Visitl ¢ G0160 OTA Visitl ¢ 0431 0551 G0163 ST Maintenance Visit l 0441 G0161 Supply Adjustments for 2013- TBA ¢ Effective date 01/01/2013 ¢ User2 field values: TBA ¢ (Make sure there are NO SPACES after the commas) ¢ User3 field values: TBA ¢ User4 field values: S=1,T=2,U=3,V=4,W=5,X=6 Supply Adjustment Code ¢ Not updated timely ¢ Not updated properly Supplies on Claims- Pitfalls ¢ Revenue codes of 0270 or 0623 are NOT entered in DME and Supply maintenance for the appropriate supplies ¢ Supplies NOT downloaded from “Create Bills for Supplies” or not entered into “Additional Services” Code Table Maintenance- for Supplies CBSA Codes ¢ Not updated timely ¢ Not updated properly ¢ Incorrect or missing rural addon percent ¢ Missing CBSA’s your agency serves RAP- Pitfalls 1. 2. 3. 4. 5. 6. 7. Missing Policy Number Invalid Referral Source Type Referral Source Type is missing Missing HIPPS Code Missing Oasis matching key Oasis assessment not approved Oasis Assessment not transmitted RAP Pitfalls- (Cont.) 8. 9. 10. 11. 12. 13. 14. Missing attending physician No Verbal SOC or 485 started No Billable Visit Invalid CBSA LUPA with more than 4 visit RAP cannot be cancelled, DCN missing RAP cannot be cancelled, payment is missing Pay Source Pitfalls ¢ Did the pay source change? From Medicare to a Medicare HMO? l From a Medicare HMO to Medicare? l ¢ The solution is to discharge and readmit! Pay Source Pitfalls Do you need an Oasis because Medicare or a Medicare HMO is secondary? ¢ The solution is to use a primary pay source that generates an Oasis! ¢ • Create a pay source that generates an OASIS that is specifically used when the secondary payer requires an OASIS. F2F -Pitfalls ¢ ¢ ¢ F2F encounter not performed F2F encounter not timely F2F encounter not found * If not completed then the patient must be discharged and you cannot bill for the service provided Therapy Threshold- Pitfalls ¢ Not identifying if assessments have been missed ¢ Assessments must be done: l l ¢ At least every 30 days Before the 13th & 19th visit for each therapy Including therapy visits on claims that occur after the mandatory assessment period Timesheet Activity TypePitfalls ¢ Missing activity types that tie to the correct “G codes” l Therapy Maintenance l Education Visit l HH POC Mgmt l Observation & Assessment l Therapy Assessment ¢ Missing discipline maintenance for timesheet activity types Final Bill- Pitfalls 1. 2. 3. 4. 5. 6. 7. Is this a SCIC is not unchecked- See next screen No Supply on Bill- check additional services or download from “Create bills for supplies” RAP is not found RAP has not been distributed RAP has not been created Wrong bill basis- means that it is not the bill basis of “15 minute units HH” F2F not timely, performed or found “SCIC is not approved” error ¢ ¢ ¢ ¢ From Oasis Transmission Occurs when another Oasis, such as resumption of care is completed Uncheck the “Is this a SCIC” box Is this correct? Oasis Transmission-Check for Approved and Transmitted Status as well as SCIC’s PPS Adjustments ¢ Estimates potential adjustments to revenue ¢ Identify and post adjustment estimates l Helps to identify under or over payments ¢ Monitor RAPSl Those that are about to expire l Those that have expired ¢ Identify accounts with therapy differences l Evaluate the cause of the differences and costs Automatic Adjustments ¢ Occurs when claim episodes begin in one year and end in a different year ¢ When rates are changed in billing and service rates ¢ Suncoast handles this “reconciliation” for you Adjustments Tab LUPA/RAP Tab Therapy Miscellaneous disasters that can happen l Have you added any new referral sources? • If so, make sure you have included a RAP code l Have you added a new pay source? • Make sure the OASIS section is set-up l Do your admit/OASIS/ 485 dates match? l Did you create a Verbal SOC? Reports- Are you missing revenue? Use these reports to help you with this. Oasis Transmission l PPS Adjustments l PPS Claim Status l Home Health-PPS l • allows the user to analyze home health care episodes for a given date range, which aids the agency in reviewing and comparing costs to revenue by discipline and HIPPS/HHRG codes. Billing Fixes¢ Make sure and keep up with changes to the system due to regulatory changes l l New rates usually effective January each year but can occur more often New regulatory changes occurring frequently ¢ Work the Bill Edit Error report throughout the month ¢ Work the PPS Adjustments reports ¢ Use your Home Health- PPS and PPS Claim status reports to gain information and insight into you’re A/R Solutions can help ¢ Attend the Instructor-led classes or use the tutorials posted on the Webex training center to learn more ¢ Let us do a “checkup” on your system Discussions Let’s check your knowledge In the following slides there are things that are wrong and right about the setups. Your job is to review the slides. ¢ Identify what you see that is wrong ¢ Identify what you see that is right LUPA Add-On- Does this look correct? PPS- Does this look correct? Does this Supply Adjustment look correct?