Document 6520531

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?