Hospice Payment Rates for Routine Home Care (RHC) on and after January 1, 2016

Current Status
04/24/2019

1. Hold Hospice Adjustments to Avoid Underpayments:
On July 2, 2018, CMS changed Medicare’s claims processing systems to better identify prior hospice days when calculating hospice routine home care payments after a transfer; see
MLN Matters Article MM10180 (PDF, 70 KB). This process is not working correctly, resulting in underpayment for these claims. CMS will fix this issue on October 7:
  • Until October 7, do not submit adjustments when there is a transfer within the benefit period
  • Beginning October 7 or after, resume submitting adjustments
  • If the dates of service are beyond the timely filing period, submit a reopening request using Type of Bill (TOB) 8XQ with remarks “RHC rate overpayment reopening for transfer situations”

2. For RHC overpayments for situations other than transfer situations, hospices may submit an:

  • Adjustment TOB 8X7 to correct RHC payments that are still within timely filing by using a D9 condition code and remarks stating “RHC rate overpayment adjustment for non-transfer situations”                           
  • Reopening TOB 8XQ with remarks stating “RHC rate overpayment reopening for non-transfer situations” for claims past the timely filing period

More information about reopening a claim may be found in MLN Matters® Number: SE1426 (PDF, 1.01 MB), Scenarios and Coding Instructions for Submitting Requests to Reopen Claims that are Beyond the Claim Filing Timeframes

Situation:
Effective January 1, 2016, two separate payment rates replaced the single Routine Home Care (RHC) rate:

  1. A higher RHC rate for days 1 through 60; and
  2. A lower RHC rate for days 61 and beyond.

An issue has been identified with the two separate payment rates for RHC services on and after January 1, 2016. On some claims, the high rate is populating on the claim for the RHC days when the low rate should have been applied.

Impact to Provider:
Overpayments have occurred on certain claims.

Status:

04/24/2019

1. Hold Hospice Adjustments to Avoid Underpayments:
On July 2, 2018, CMS changed Medicare’s claims processing systems to better identify prior hospice days when calculating hospice routine home care payments after a transfer; see
MLN Matters Article MM10180 (PDF, 70 KB). This process is not working correctly, resulting in underpayment for these claims. CMS will fix this issue on October 7:

  • Until October 7, do not submit adjustments when there is a transfer within the benefit period
  • Beginning October 7 or after, resume submitting adjustments
  • If the dates of service are beyond the timely filing period, submit a reopening request using Type of Bill (TOB) 8XQ with remarks “RHC rate overpayment reopening for transfer situations”

2. For RHC overpayments for situations other than transfer situations, hospices may submit an:

  • Adjustment TOB 8X7 to correct RHC payments that are still within timely filing by using a D9 condition code and remarks stating “RHC rate overpayment adjustment for non-transfer situations”                           
  • Reopening TOB 8XQ with remarks stating “RHC rate overpayment reopening for non-transfer situations” for claims past the timely filing period

More information about reopening a claim may be found in MLN Matters® Number: SE1426 (PDF, 1.01 MB), Scenarios and Coding Instructions for Submitting Requests to Reopen Claims that are Beyond the Claim Filing Timeframes

3/21/2019 - Palmetto GBA is testing the fix that was implemented on March 4, 2019. We will provide an update as soon as available and instruction to correct the underpayments or overpayments. No provider action is required at this time.

2/15/19 - Some hospice adjustments continue to process with incorrect high/low payment rates for RHC services. A fix to this issue is scheduled for implementation on March 4, 2019. We will provide an update as soon as available. No provider action is required at this time.

11/30/2018 - The two separate payment rates for RHC services continues to be an issue and may result in underpayments or overpayments. We will provide an update as soon as available. No provider action is required at this time.

9/21/2018 - The two separate payment rates for RHC services continues to be an issue and is in research. We will provide an update as soon as available. No provider action is required at this time.

3/13/2018 - Palmetto GBA has identified an ongoing issue with the two separate payment rates for RHC services. High rates instead of low rates are being incorrectly applied for claims processed after the correction implementation on August 21, 2017. The August fix did correct a majority of the issues, but some overpayments are continuing.

As a reminder, providers should not report system issue overpayments on their Quarterly Credit Balance Reports, since it will be taken back when the issue is corrected and the claims are adjusted. Providers should also not submit refunds or appeals to attempt to correct the issue, as the MACs cannot override the issue at this time. The overpayments will be settled once the issue is fixed and the claims are able to adjudicate correctly. Hospices should still follow the workaround instructions for transfers as specified in MLN Matters Special Edition article SE17014 (PDF, 256 KB). until notified. No provider action is required at this time. 

9/28/2017As stated in
SE17029 (PDF, 165 KB) (Process for Hospices to Submit a List of Claims Requiring Adjustments), provider may submit adjustments or submit a list of claims to the MAC for adjustments. To avoid MACs making multiple adjustments on the same claim, providers are advised to send only one list, in an Excel spreadsheet format, containing all claims to be adjusted. After reviewing, the hospice should submit to the MAC a list of claim information that includes the following:

  • The document control numbers (DCNs) of the claims to be adjusted,
  • The dates of service for each claim, and
  • Whether the error is related to RHC days or SIA amounts.

Do not submit PHI or PII patient information on the list. If a hospice provides a list, they should do so no later than October 20, 2017. The MAC will initiate the adjustments over the three months following the submission of all lists, concluding the process by January 19, 2018.

Providers shall email the list to: Removed due to time frame for submission has expired.

9/12/2017: Palmetto GBA is adjusting claims to test if the August 21, 2017, system fix eliminated calculating an incorrect payment if the prior days used are greater than 99 (as described in SE 17014). Providers may continue to adjust any claims that received an incorrect payment amount for RHC days when the prior days used are less than 99. Once the fix is confirmed, Palmetto GBA will offer a process for providers to submit claims for contractor adjusting. We will provide an update as soon as available. Providers should NOT submit voluntary refunds or report system issue overpayments on their Quarterly Credit Balance Reports for an ongoing system issue. The overpayments will be settled once the issue is fixed and the claims are able to adjudicate correctly.

5/30/2017: Hospices shall submit adjustments to correct payment errors. Medicare has corrected most of the system errors associated with 2016 hospice service intensity add-on and routine home care payments; however, Medicare cannot accurately re-process claims for two issues. Hospices should submit claims adjustments as specified in
MLN Matters Special Edition article SE17014 (PDF, 256 KB). 

4/27/2017: Some claims are continuing to have the RHC high rate applied in error. This issue is being researched. We will provide an update as soon as available. No provider action is required at this time.

4/6/2017 – Corrections have been implemented with the April 2017 Release. 

2/9/2017: A fix to this issue has been created and is scheduled to be released into production on April 3, 2017. Palmetto GBA is awaiting further direction to correct previously processed claims with incorrect payment amounts. No provider action is required at this time.

12/30/16: Claims for dates of service on or after October 1, 2016, (Hospice FY 2017) are continuing to have the RHC high rate applied in error. This issue is being researched by the FISS Maintainer and Palmetto GBA. We will provide an update as soon as available. No provider action is required at this time.

12/6/16: The fix for this was implemented on December 5, 2016. Palmetto GBA is awaiting further direction to correct previously processed claims with incorrect payment amounts. No provider action is required at this time.

11/23/16: The fix to this issue has been delayed for release into production until December 5, 2016. Palmetto GBA is awaiting further direction to correct previously processed claims with incorrect payment amounts. No provider action is required at this time.

10/21/16: The fix to this issue has been delayed for release until November 21, 2016. Palmetto GBA is awaiting further direction to correct previously processed claims with incorrect payment amounts. No provider action is required at this time.

9/28/16 - A fix to this issue has been created and is scheduled to be released into production on November 7, 2016. Palmetto GBA is awaiting further direction to correct previously processed claims with incorrect payment amounts. No provider action is required at this time.

8/29/16 - Palmetto GBA has identified an ongoing issue with the two separate payment rates for RHC services. High rates instead of low rates are being incorrectly applied for claims processed after the correction implementation on July 25, 2016. We have escalated the issue to the FISS Maintainer.

8/12/16 - Two recent systems issues caused routine home care days to be miscounted on hospice claims:

  • Systems were not counting days that should receive high routine home care payments if a revocation was posted on the benefit period before the final claim was submitted. A correction was implemented on May 9, 2016.
  • Systems were using the election date instead of the admission date when a prior hospice period was involved. A correction was implemented on July 25, 2016.

Medicare Administrative Contactors are adjusting hospice claims to correct payment for dates of service on or after January 1, 2016. All adjustments to correct these two problems shall be completed in the next 90 days. Hospices do not need to take any action.

5/4/16 – There is a change to the scheduled fix date, which is currently expected to be corrected in the January 2017 quarterly release.

3/4/16 - Palmetto GBA has received a response that the issue is expected to be corrected in the July quarterly release. As a reminder, providers should not report system issue overpayments on their Quarterly Credit Balance Reports, since it will be taken back when the issue is corrected and the claims are adjusted.

2/19/16 - This issue has been reported to the Fiscal Intermediary Shared System (FISS) Maintainer. No provider action is required at this time.

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