CMS to Fix Claims Issues, Revises Appeal Rules

The U.S. Centers for Medicare & Medicaid Services (CMS) is working to fix bugs in the Medicare claims processing system resulted in underpayments to hospices during 2018 and early 2019. The agency also alerted hospices to revised rules for electronic signatures and appeals.

CMS last year altered Medicare’s claims processing systems to better identify prior hospice days when calculating hospice routine home care payments after a transfer. The new system has not been including days provided by another hospice when a patient has switched providers during the benefit period, resulting in underpayment, according to the agency. CMS expects to have the issues resolved by Oct. 7.

Until the system problems are resolved, CMS has requested that hospices do not submit adjustments where there is a transfer within the benefit period. But if dates of service are beyond the timely filing period, the hospice should submit a reopening request using Type of Bill 8QX.

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“Medicare pays a higher rate for routine home care hospice services during the first 60 days of service. Because the number of prior service days cannot be identified in all cases by the Fiscal Intermediary Shared System (FISS) from the face of the claim, the Common Working File (CWF) must read data from services provided at other hospices and return additional days that apply to the payment calculation to FISS,” the agency indicated. “To date, Medicare has instructed the CWF to identify prior service days based on prior benefit periods. This overlooks the possibility that service days may have occurred at another provider prior to a transfer within the same benefit period.”

Regarding timely signatures, CMS updated its Medicare Claims Processing Manual to reflect regulatory amendments allowing signatures for representative instruments providers to the agency to be handwritten or electronic, digital, and/or digitized, via mail, facsimile, or a CMS-approved secure internet portal or application.

The agency in addition revised policies governing appeals for claim decisions for physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), applicable to hospice, home health, durable medical equipment.

According to the revised rules, MACs must document on the appeal decision letter or case file when they find good cause for late filing. The revisions also add processes for appeals that occur as a result of a natural or man-made disaster.