Time’s running out for some Medicare claims

Here’s how to keep future claims from stacking up

If you’ve put off submitting, or in some instances resubmitting, your Medicare claims from Jan. 1, 1999, through Sept. 30, 2000, your time is running out. They’re due by Dec. 31, 2001.

As most home health care agencies know, Medicare claims can get lost in the shuffle. Even when they don’t, your agency might not be reimbursed for some claims, although Medicare will hold onto claims with known errors for up to 60 days.

If no corrective action is taken within that time, these files are deleted and your agency is back to square one. Sometimes, even when your intermediary sends notification of a claim error, these notices can find their way to the bottom of a tall stack of to-do’s, never to resurface again.

According to Christine Cloutier, RN, owner and president of Christine Cloutier Consultants in South Portland, ME, if you’re looking to submit your back claims, "this is the last minute."

Her consulting company, she says, "recently [has] gone into an agency and left one of our staff there on full-time basis. We’re finding claims with literally hundreds of visits that have never been billed."

While it might sound like gross negligence on the part of this agency, that’s not the case, Cloutier says. "I think most agencies are regularly going through their claims. It’s not neglect at all, but it really takes a full-time person to at least review suspense files daily, make corrections, reconcile things, and review the postings.

"That very often can be a huge problem because in any given agency, it might be short-staffed or still doing manual postings," she adds. "And with the new PPS [prospective payment system], I honestly feel sorry for [that agency]."

Being short-staffed, while adding to an agency’s workload, isn’t the only reason Medicare claims may have errors or go unbilled.

"There are so many varying issues, but a lot start in intake when someone transposes an insurance number," explains Cloutier. "The claim will go through the system until that number is picked up. There have been many times when we have found months of service billed under the wrong insurance number."

OASIS data could cause problems

Outcome and Assessment Information Set (OASIS) data also can be the source of problems, she notes, especially where the nursing staff does the intake.

"It’s so essential that they complete the OASIS correctly so that it merges with their internal data system," she says. "Another thing under the new PPS is that a nurse might admit a patient on Oct. 1, but won’t sit down to do the OASIS paperwork until a few days later. Then the start-of-care date will show up as Oct. 3, for example, although it really began two days before."

What’s more, she says, is nurses need to be careful when filing discharges.

"A patient might be discharged within the 60-day rule," she says, "but if for some reason that date gets deleted, it will appear that treatment was ongoing."

In some cases, the biller, maybe a home care aide, is not really experienced and will bill a 4-unit increment (one hour or service) when in fact it was two hours and should be billed as an 8-unit increment, she explains.

"In these cases, you get into the hourly vs. per-visit issue, and people simply aren’t doing the conversion correctly," she says.

Another large problem area lies with adjustments from the Medicare side. "A claim very often will be paid, but when we go back and compare what Medicare paid and the actual charges, we’ll find that it’s $2,000 off."

Watch out for software glitches

Patience and accuracy may be virtues, but they won’t always help when computers are factored in. Cloutier points out that while human error is the cause of some Medicare billing issues, so is an agency’s software.

"A lot of problems stem from the fact that many providers use software systems that are still working out the wrinkles," she says. "Many issues like status codes and dates were not properly instituted by software vendors or simply didn’t merge with existing systems."

In such cases, she advises running, not walking to your software provider. She recounts the story of one agency for which she was consulting recorded every problem and glitch staff encountered.

"When we approached the vendor, it was more than willing to work with us and quickly remedy the problem," she says.

Vigilance is the key

To keep claim errors at bay, Cloutier urges agencies to run regular checks.

"The way to correct and catch an error is to go into suspense files every day after recent a submission of claims," she suggests. "If you do this, you’ll find the errors."

She encourages her clients to run regular aged receivables reports through the Medicare system. "It’s the first thing we ask them to do. Then we look at the bottom line. Agencies should test their claims and the best way is on the Medicare system because the system either will give you a pay date or will say that the particular claim doesn’t exist."

Dana Strong, owner and president of Strong Consulting LLC in Scarborough, ME, also recommends that agencies make sure their Medicare cash receipts tie back to the agency’s records.

"In my experience, it’s well worth it to take
all these steps," says Cloutier, whose firm has recently started a contingency-based Medicare claims processing and review program.

"We have found millions of dollars in unclaimed bills, and even in smaller agencies, amounts up to $40,000," she says. "That translates to the agencies. It translates to a few salaries."

[For more information, contact:

  • Christine Cloutier, Owner and President, Christine Cloutier Consultants, 126 Fickett St., South Portland, ME 04106. Telephone: (207) 767-1309.
  • Dana Strong, Owner, President, Strong Consult-ing LLC, One Steeplechase Drive, Scarborough, ME 04074. Telephone: (877) 763-9252.]