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CMS Corrects Home Health Prospective Payment System Outlier Limitation

by Published On: May 06, 2011

Due to an error in the calculation of the Home Health Prospective Payment System (HH PPS) 10% outlier limitation, the outlier payment has been calculated incorrectly since Jan. 1, 2010. 

According to the Center for Medicare and Medicaid Services (CMS) MLN Matters article number MM7395, all home health agencies (HHA) that bill Regional Home Health Intermediaries (RHHI) for services provided to Medicare beneficiaries are affected.

Beginning Jan. 3, 2012, CMS will adjust all claims with outlier payments paid or withheld for dates of service since Jan. 1, 2010 by reprocessing all HH PPS claims with outlier limitations applied in error. 

Reprocessing of claims will begin Jan. 3, 2012, and CMS expects most claims will result in an underpayment, although there may be some cases where CMS will be collecting an overpayment.

Specifically, effective for claims with dates of service on or after Jan. 1, 2010, Medicare systems will:

  • Update each HHA’s year-to-date outlier payments and year-to-date total HH PPS payment as each claim is processed in addition to the end of each processing day.
  • When sending an HHA’s PROV-OUTLIER-PAY-TOTAL and PROV-PAYMENT-TOTAL to the HH Pricer, Medicare will use the amounts updated by the most recent prior claim.
  • Adjust outliers claims paid in excess of the 10% outlier limitation as part of quarterly HH outlier reconciliation process.
  • Complete the current process of adjustments to claims with Pricer return code 02 before taking any steps to identify outlier claims paid in excess of the 10% limitation.
  • Read each HHA’s provider year-to-date outlier payment and total payment amount and identify any provider that has been paid more than 10% in outlier payments.
  • For each identified HHA, calculate the dollar amount of outlier payments that has been paid in excess of 10%.
  • For each identified HHA, create a report of outlier claims currently in paid claims history with outlier payments up to but not exceeding the dollar amount calculated.
  • For each identified HHA, create a report of outlier claims currently in paid claims history with outlier payments up to, but not exceeding, the dollar amount calculated.

For official CMS instructions issued to your RHHI, you can download CR7395. 

 



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