CMS surveys need for eligibility data

Monday, December 6, 2010

BALTIMORE – Could better access to eligibility data on Medicare beneficiaries be on the way?

CMS sent out a six-question survey recently, asking various providers whether the need for eligibility data has increased in the past two years. HME providers and stakeholders contacted by HME News say it has, largely because following the plan of care of beneficiaries has become harder and harder.

“With some beneficiaries, especially those who have been using supplies for a long time, providers don’t know when they’re in a home health episode until well after the fact and by then it’s too late for them to bill the home health agency directly,” said Rose Schafhauser, executive director of the Midwest Association of Medical Equipment Services (MAMES), who alerted her members of the survey in a recent bulletin. “Providers are usually the last to know.”

When providers don’t know that a beneficiary has entered a home health episode and they continue to bill Medicare for supplies instead of the home health agency, it raises a red flag that CMS and its contractors are increasingly picking up on in audits, stakeholders say.

Making things worse: When the home health agency takes its time notifying Medicare that a beneficiary is in a home health episode, one provider says.

“At some point, they submit a claim, backdating it, and we look like a fraudulent provider,” he said. “Of course, we’re not.”

So what are providers to do?

“My advice to providers is that, as soon as you get a denial, you really should do a retrospective query or eligibility verification to make sure last month’s claim wasn’t impacted, so that when they go through and do these audits, you’ve already initiated the voluntary recoupments,” said Andrea Stark, a reimbursement consultant with MiraVista. “That’s something providers are starting to pick up on.”

CMS says it conducted the survey for “planning purposes.”

“We are always planning changes to improve our eligibility systems,” said Peter Ashkenaz, a CMS spokesman. “Through these questions, we were seeking information from Medicare providers for planning purposes as we estimate future capacity requirements.”