Fix overlap flap, AAH tells CMS

Wednesday, January 9, 2013

BALTIMORE – AAHomecare has gone to bat for HME providers who are losing out on monthly payments from Medicare for claims that overlap inpatient stays.

The association, which discussed the problem with CMS recently, says Recovery Audit Contractors (RACs) are seeking recoupment on claims when the anniversary billing date overlaps with a patient’s stay in a hospital, skilled nursing or other facility—even if the patient uses the equipment nearly every day during that month.

“This is a threat to all providers,” said Walt Gorski, vice president of government affairs for AAHomecare. “And, as audit activities increase, this problem will only get worse. The RACs and the auditors are using homecare providers as an ATM.”  

AAHomecare has asked CMS to tell auditors not to recoup a payment based solely on an anniversary billing date that corresponds with an inpatient stay. If the patient uses HME in the home at any time within the billing cycle, the payment should stand. In cases where a payment has already been recouped, CMS should allow the provider to reopen the claim process or submit a revised claim.

Medicare rules do allow providers to change the anniversary billing date when they learn it will overlap with the date a patient enters an inpatient facility, as a way to ensure payment, says healthcare attorney Edward Vishnevetsky.

“The problem is, when you are doing it through the RAC, you are usually past the timely filing period,” said Vishnevetsky, an associate at Munsch Hardt Kopf & Harr.

That’s because, while Medicare’s billing system can catch many of these claims in real-time, the Part A facility may take up to a year to file its claim.

“You have no recourse,” said Gorski. “Even though you provided services to that beneficiary, you have to pay it back.”

Another contractor, the Zone Integrity Program Contractors (ZPICs), has been auditing these types of claims since 2008, Vishnevetsky says.

“The RAC auditors have obviously caught on to that,” he said.


Everyone should be on notice that as of now the industry can't file anything with The Federal Courts for relief.  Any attempt to file anything will almost inevitably be denied on arrival!!