A Medicare Administrative Contractor (MAC) can deny a hospice claim for a wide range of reasons, but two types of errors stand out that can lead to a rejection.
A few causes of denials are widely known. They stem almost entirely from documentation errors or omissions such as a physician’s signature on the certification form or other indications that a patient may not be eligible for hospice or for a particular level of care, such as General Inpatient Care.
However, other factors frequently come into play that can lead to a denial or, if a pattern of errors emerges, a Target, Probe and Educate (TPE) audit, Erin Musumeci, provider outreach and education consultant for the MAC National Government Services (NGS), said at the National Hospice and Palliative Care Organization (NHPCO) Annual Leadership Conference.
“Providers that might have high claim-error rates or unusual billing practices — or items or services that have high national error rates — those are financial risks to Medicare,” Musumeci said at the conference. “A lot of providers and suppliers will never need or might not ever need TPE. Rather, the process is used with those who have a high denial rate or or unusual billing practice.’
One common reason for rejection is a duplicate claim.
Providers submit duplicates for a variety of reasons, including simple oversights. But in some instances, a provider that hasn’t received payment may assume that the MAC did not receive or lost the claim will submit it a second time.
In other instances, a provider’s billing staff may realize that something was omitted from the original claim and resubmits it with additional information. This too will result in a rejection. The correct process is to adjust the claim after it was adjudicated, according to Andrea Freibauer, also a provider outreach and education consultant for NGS.
Medicare’s automated claims processing systems are designed to identify these kinds of errors.
“The vast majority of claims are not seen by human eyes in the Medicare claims processing system. These are automatic,” Freibauer said at the NHPCO conference. “The claim comes in and it says, ‘Oh, there’s another one exactly like this, or that has the same codes on it, same date of service.’ It pops it right out.”
Providers should ensure that billers are taking steps to ensure that the hospice is not sending duplicative claims.
Dates of service vs. time of death
In addition to slowing down payments or losing revenue, submitting inadequate or incomplete required written documentation is a sure-fire way to bring surveyors or auditors to a hospice’s doorstep. As regulators increasingly fix their eyes on the hospice space, providers are stepping up their efforts to ensure their documentation is airtight to avoid claims denials.
One key area to watch are the dates of service listed on claims. A common reason for claims rejection is that dates of service listed on the documentation came after the patient’s time of death.
This may occur due to clerical errors, but providers will have to do a little digging to find where the mistake occurred. For example, they need to determine whether the service dates are inaccurately listed or the time of death.
Freibauer said that personnel that prepare claims should make sure to check the patient’s Medicare beneficiary number and double check all relevant dates.
“If the actual date of death was reported to Social Security in error, that you have to contact Social Security in order to have that date corrected,” Freibauer said at the NHPCO conference. “Otherwise, once the system has been updated to show the correct data, then you can go and resubmit that claim or that appeal.”