Beneficiary-Driven Demand Billing Under HH PPS

50 - Beneficiary-Driven Demand Billing Under HH PPS (Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21) Demand billing is a procedure through which beneficiaries can request Medicare payment for services that: (1) their HHAs advised them were not medically reasonable and necessary, or that (2) they failed to meet the homebound, intermittent or noncustodial care requirements, and therefore would not be reimbursed if billed. The HHA must inform the beneficiary of this assessment in an Advance Beneficiary Notice of Noncoverage (ABN), which also must be signed by the beneficiary or appropriate representative. Instructions for the ABN are found in chapter 30 of this manual. Beneficiaries pay out of pocket or third party payers cover the services in question, but HHAs in return, upon request of the beneficiary, are required to bill Medicare for the disputed services. If, after its review, Medicare decides some or all the disputed services received on the “demand bill” are covered and pays for them, the HHA would refund the previously collected funds for these services. If the Medicare determination upholds the HHA’s judgment that the services were not medically reasonable and necessary, or that the beneficiary failed to meet the homebound or intermittent care requirements, the HHA keeps the funds collected, unless the A/B MAC (HHH) determines the ABN notification was not properly executed, or some other factor changed liability for payment of the disputed services back to the HHA. A. Interval of Billing The Medicare payment unit for home care under the home health prospective payment system (HH PPS) is a period of care, usually 30 days in length. A Notice of Admission (NOA) must be submitted for a beneficiary before any claims can be processed. A claim is submitted for every 30 days of HH services. This does not change in demand bill situations. B. Timeliness of Billing Medicare requests that HHAs submit demand bills promptly. Timely filing requirements apply to HH PPS claims in the same manner as other claims (see chapter 1 for information on timely filing). Medicare has defined “promptly” for HH PPS to mean submission at the end of the period of care in question. The beneficiary must also be given either a copy of the claim or a written statement of the date the claim was submitted. C. Claim Requirements HH PPS claims, including demand bills, are submitted with TOB 0329, and provide all other information required on that claim for the HH PPS period of care, including all visit-specific detail. The HHA must NOT use TOB 0320 when submitting a demand bill. The HHA must report condition code “20” and the services in dispute shown as noncovered line items. Demand bills may be submitted with all noncovered charges. Provision of this additional information assures medical review of the demand bill. Cases may arise in which the services in dispute are visits for which an HHA has physician’s orders, but the duration of the visits exceeds Medicare coverage limits. However, the portion of these visits that is not covered by Medicare may be covered by another payer (e.g., an 8-hour home health aide visit in which the first 2 hours may be covered by Medicare and the remaining 6 hours may be covered by other insurance). In such cases, HHAs must submit these visits on demand bills as two line items. One line will represent the portion potentially covered by Medicare with a covered charge amount and units reporting the Medicare-covered visit time. The second line will represent the portion to be submitted for consideration by other insurance with a noncovered charge amount and units reporting non-Medicare visit time. Cases may also arise in which a State Medicaid program requests the demand bill on the beneficiary’s behalf regarding services which have been billed to Medicaid. In these cases, the dates of service for which the State requests the demand bill may not correspond exactly to the periods billed to Medicare. These cases require special instructions: Requests regarding services not expected to be billed to Medicare: A Medicare-Medicaid dually-eligible patient may be admitted to home care with the expectation that no services will be billed to Medicare. Later, the State may request demand bills beginning during the course of that care. This may occur when requests correspond to a calendar year. For example, the patient may be admitted in December and the request for demand bills is effective January 1. In this case, the HHA should submit a demand bill to Medicare with period of care dates that began in December. All services should be submitted as non-covered line items. As with any demand bill, condition code 20 should be reported on this claim. Request applies to services immediately following Medicare discharge: A dually-eligible patient may be discharged from Medicare home health services before the end of a 30-day period of care due to the patient meeting their treatment goals. The patient may remain under the care of the HHA receiving services billed to Medicaid. States may vary in their requirements for a new Start of Care OASIS assessment in these cases. If the State requesting a demand bill for the services within the original 30-day period of care does not require a new OASIS assessment, the HHA should submit an adjustment to their previously paid Medicare claim, using TOB 0327. The HHA should add condition code 20 to the adjustment claim, change the statement “Through” date to reflect the full 30-day period and add the services provided during the demand bill request period as non-covered line items. The HHA should then submit claims with condition code 20 and all non-covered line items for any periods of continuous care within the demand bill request period. If the State requesting a demand bill for the services within the 30-day period of care requires a new OASIS assessment, the HHA should submit an NOA and submit claims with condition code 20 as they would for any other demand bill situation. When Medicare receives the NOA for the demand billed episode it will cause a partial period payment adjustment to apply to the prior period. Medicare cannot presume that the demand billed period will or will not be covered based on the NOA. If the claim for the demand billed period is later reviewed and found to be entirely non-covered, Medicare systems will automatically adjust the prior period to restore the appropriate full episode payment. D. Favorable Determinations and Medicare Payment Results of Medicare determinations favorable to the party requesting the demand bill will not necessarily result in increased Medicare payment. In such cases, and even if a favorable determination is made but payment does not change, HHAs will still refund any monies collected from beneficiaries or other payers for services previously thought not medically necessary under Medicare. Medicare payment will change only with the addition of covered visits if one or more of the following conditions apply: • An increase in the number of overall visits that either: 1. Changes payment from a low-utilization payment adjustment to a full period payment; or 2. Results in the period of care meeting the threshold for outlier payment. • A favorable ruling on a demand bill adds days to a claim paid a partial period payment adjustment. If a favorable determination is made, A/B MACs (HHH) will assure pricing of the claim occurs after medical review so that claims also serving as demand bills receive appropriate payment. E. Appeals Appeal of Medicare determinations made on HH PPS claims also serving as demand bills is accomplished by appealing the HH PPS claim. Such appeals are done in accordance with regulations stipulating appeals rights for Medicare home health claims. F. Specific Demand Billing Scenarios 1. Independent Assessment -- Billing questions relative to the ABN and home health assessments. With regard to payment liability for the assessment itself, the assessment is a non-covered service that is not a Medicare benefit and is never separately payable by Medicare. In all such cases, a choice remains: The provider may or may not decide to hold the beneficiary liable, and Medicare cannot specify which is appropriate because the service at issue is outside Medicare's scope. If a decision is made to hold a beneficiary liable for just the assessment, Medicare providers must be in compliance with the home health Conditions of Participation (COPs), as follows: 42 CFR 484.10.e (1) The patient has the right to be advised, before care is initiated, of the extent to which payment for the HHA services may be expected from Medicare or other sources, and the extent to which payment may be required from the patient. Before care is initiated, the HHA must inform the patient, orally and in writing, of: (i) The extent to which payment may be expected from Medicare, Medicaid or any other Federally funded or aided program known to the HHA; (ii) The charges for services that will not be covered by Medicare; and (iii) The charges that the individual has to pay. Therefore, while no notice may be required if the provider chooses to be liable, the conditions state a notice is required if the beneficiary is to be held liable, and must be delivered prior to the service in question. ABNs can be used for this purpose. 2. Billing in Excess of the Benefit. In some states, the Medicaid program will cover more hours of care in a week than the Medicare benefit. Therefore, an HHA may be billing hours/visits in excess of the benefit during a Medicare home health period of care for a dually eligible beneficiary. Since the care delivered in excess of the benefit is not part of the benefit, and does not affect the amount of Medicare’s prospectively set payment, there is no dispute as to liability, and an ABN is not required unless a triggering event occurs; that is, care in excess of the benefit is not a triggering event in and of itself requiring an ABN. Billing services in excess of the benefit is discussed in C in this section. 3. One-Visit Periods. Since intermittent skilled nursing care is a requirement of the Medicare home health benefit, questions often arise as to the billing of one-visit periods of care. Medicare claims systems will process such billings, but these billings should only be done when some factor potentially justifies the medical necessity of the service relative to the benefit. Many of these cases do not even need to be demand billed, because coverage is not in doubt, since physician orders called for delivery of the benefit. When the beneficiary dies after only one visit is a clear-cut example. When physician orders called for additional services, but the beneficiary died before more services could be delivered, the delivery of only one visit is covered. The death is indicated on the claim with use of patient status code 20. Other cases in which orders called for additional services, but circumstances prevented delivery of more than one service by the HHA, are also appropriately billed to Medicare in the same fashion. There may be rare cases where, even though orders do not clearly indicate the need for additional services, the HHA feels delivery of the service is medically justified by Medicare’s standard, and should be covered. In such situations, when doubt exists, an HHA should still give the beneficiary an ABN if a triggering event has occurred, explaining Medicare may not cover the service, and then demand bill the service in question. No billing is required when there is no dispute that the one service called for on the order does not meet the requirements for the Medicare home health benefit, or is not medically necessary. However, there are options for billing these non-covered services as discussed in chapter 1, section 60 of this manual. Note the COPs may require notification in this situation if the beneficiary is to be held liable, as discussed in number 1, immediately above.