F.O.R.C.E. Healthcare Resources, LLC (Founded on Regulatory Compliance and Ethics) How to Avoid the Most Common Home Health Billing Errors October 17,

About F.O.R.C.E.? Home Health Consulting Firm – Founded 2005 Services Provided: 1.Home Health Billing Webinars 2.Home Health Outsource Billing 3.Home Health Outsource Medical Coding 4.Home Health Billing Clean-up Projects 5.Home Health Operation / Process Consulting 6.Home Health Financial Consulting 7.Home Health CLIA Billing & Recovery Project 2

Contact Information F.O.R.C.E Healthcare Resource, LLC. –Website: Terri Ready, COO -Direct: ext Mobile: Lynn Alley, Billing Supervisor –Direct: Jonathan Sellers, Sales & Marketing - Direct:

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Impact of Claim Rejections and RTP’s Cash Flow -No claim payment on first submission -Delays in payment if adjustment claim is required -Potential conflicts if arrangements not made prior to services being rendered 5

Impact of Claim Rejections and RTP’s Staff Time -Research needed to determine correct beneficiary status or situation related to claim status -Submitting new claim or adjustment as appropriate 6

Benefits of Preventing Rejections/RTP’s Increase Medicare Cash Flow Decrease time spent correcting RTP’s, adjusting or submitting new claims Agency gets paid/Employees get paid Everyone is Happy!!!! 7

Determine Claim Status-Location Denials (D B9997)- Claims must be appealed Rejections (R B9997)- Claims are resubmitted In limited situation claims are adjusted Returned to Provider (T B9997) Claims are corrected and resubmitted 8

9 At the main Menu Choose 03 for Claims Correction

10 Choose 27 to correct a “returned to provider” claim

11 Select your claim, make your corrections, then press F9 to resubmit the corrected claim

Duplicate Claim Rejections Claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same: Health Insurance Claim (HIC) Number Type of Bill (all three positions of any TOB) Provider Number Statement from and through dates of service Total charges (0001 revenue line) Revenue Code HCPCS and Modifiers 12

Duplicate Claim Rejections Claim is a duplicate of a previously submitted Home Health claim. The first two positions of the TOB are 32X, 33X, or 34X and the following fields on the history and processing claim are the same: HIC Number Provider Number Statement ‘from’ date of service Statement ‘to’ date of service Revenue Code HCPCS and modifiers 13

Duplicate Claim Rejections The home health claim was submitted as a Medicare primary claim and contains exact service dates corresponding to a previously submitted claim for the same provider with at least one matching revenue code. 14

Actions Required If claim is an exact duplicate of a processed claim – No Action Required If Original claim needs to be adjusted to correct submission – Send additional/ corrected information on an adjustment bill type (XX7) If two claims were submitted at the same time and duplicated against each other – Submit a new claim 15

16 At the Main Menu choose 03 for claims correction.

17 Then choose 33 for Home Health claim adjustment

18 Your “adjustment claim” will now have a bill type of 327 assigned to it

Be Proactive to Prevent Submission of Duplicate Claims Know when to adjust claims rather than submit new claims. Establish internal processes to ensure duplicate claims are not being submitted Always verify prior records before submitting claims re: check FISS/remittance advices for previous claims 19

Potential for Audit Your contractor retains records of billing accuracy & have established error rate thresholds You can be turned over to a program safeguard contractor for review if the error rate thresholds are exceeded Duplicate claims is one of the top errors made by home health agency billers 20

Rejection Codes U The services on this claim overlap a Medicare Advantage / Health Maintenance Organization enrollment period 21

Rejection Code U5233 Action required: -Submit claim for MAO members to the MA plan -Check HIQH for MAO information and resubmit the claim if the CWF has been updated to show traditional Medicare coverage for the service period being billed 22

Rejection Code U5233 Avoiding this rejection: -Verify patient’s insurance information at time of admission and prior to billing Medicare -Ask the beneficiary about insurance changes -Check CWF before sending claims to ensure accurate claim reporting 23

Rejection Code Duplicate RAP of a paid RAP or paid, suspended or denied home health claim for the same provider, Medicare number and statement from date without a cancel date. - When RAP and final claim are submitted at the same time -When RAP is submitted after one has already processed -When RAP is submitted after episode claim has processed 24

Rejection Code Action Required: -Submit the RAP and wait for it to complete processing before submitting a final claim for the episode -If a final claim has processed and needs to be corrected, the RAP should not be resubmitted – send an adjustment to the finalized paid claim 25

Rejection Code Avoiding this Rejection: -Submit the RAP before submitting the final episode claim -Always verify prior records before submitting your RAP claim -Check FISS/remittance advice for previous RAP / claim submission -Establish internal process to ensure duplicate claims are not being submitted 26

RTP Reason Code U538I When a RAP or home health claim (final or LUPA) is overlapping an existing episode with a different provider number. -Add condition code 47. Which replaced admission source code “B” effective 7/1/10. “Transfer from another agency” -If the claim is a final or LUPA, verify the patient status. If the claim is less than 60 days between episodes do not use ‘01’ or ‘30’. Do use a patient status

RTP Reason Code U538I Action Required: -Verify open episode in CWF/HIQH -Contact HHA with open episode to verify transfer -Use appropriate claim coding – Condition code 47 should be used on the admitting agency’s RAP when patient is a transfer from another HHA 28

RTP Reason Code U538I Avoiding this RTP: -Check the CWF when accepting a new patient to ensure there is no other HHA established as the patient’s primary agency -Talk to the beneficiary about any other care they are receiving in the home -Admission Nurse should be careful to observe for signs in the home that another HHA might be involved 29

RTP Reason Code Source of admission code is missing or invalid for the dates of service on the claim. A source of admission code is required on this claim. - If dates of service are on or after 1/1/08, source of admission codes ‘A’ and ‘3’ are no longer valid. -If dates of admission codes are on or after 7/1/10, source of admission codes ‘7’, ‘B’ and ‘C’ are no longer valid. -Effective with dates of service 4/1/2011 the point of origin code of 9 is allowed for all TOB’s. 30

RTP Reason Code Action Required: - Verify the source of admission code billed is accurate and valid 31

RTP Reason Code N5052 The Centers for Medicare & Medicaid services (CMS) Common Working File indicates the beneficiary’s name and health insurance card number do not match. 32

RTP Reason Code N5052 Action Required: -Verify the Medicare number, spelling of the beneficiary’s name and other beneficiary information and that the information is submitted in the proper fields -Send the claim back through the system with correct information - Check CWF (HIQH) for a correct Health Insurance Claim number and resubmit with the correct number 33

RTP Reason Code N5052 Avoiding this RTP Reason Code -Verify patient information in HIQH prior to submitting claims -Check that the correct name is submitted under the appropriate Medicare number and that all beneficiary information is submitted in the proper fields on the claim 34

RTP Reason Code Invalid or missing Medicare Health Insurance Claim (HIC) number, or the alpha suffix or prefix of the Medicare HIC number is not valid. 35

RTP Reason Code Action Required: -Verify the patient’s full name, including initials. If the name has been changed, the CWF will need to be corrected. -Verify the spelling of the patient’s first and last name, including initial. -Verify the patient’s HIC number as recorded on their Medicare card -Verify that there is a HIC number on the claim, and that it is complete. 36

RTP Reason Code U538F A RAP or HH claim overlap an existing episode with the same provider number and the “From” date equals the episode’s start date. 37

RTP Reason Code U538F Action Required: -Review Claim History -Verify if billing is for initial or subsequent episode -Note only initial RAPs/claims should have the same dates in the “From” and “Admission Date” fields 38

RTP Reason Code U538F Avoiding this RTP Reason Code: -Always verify prior billing using the FISS system/your remittance advices -Establish an internal process or checklist of systems and information that must be confirmed before submitting claims to Medicare 39

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