Error To Be Corrected: Incorrect Recoupment of Home Health Outlier Payments
Tuesday, June 4, 2013
by: VNAA Policy Team

Section: Public Policy and Advocacy




The May 2013 reconciliation process for outlier payments contained errors that caused the data in the outlier totals for prior years for many home health agencies (HHA) to be corrupted. Claims adjustments were triggered based on the incorrect total amounts and outlier payments that were not actually over the cap were erroneously recouped.

To relieve potential financial hardship that this may cause, the Centers for Medicare and Medicaid Services (CMS) has directed all home health Medicare Administrative Contractors (MACs) to take action by issuing lump sum payments to agencies with total outlier claim adjustments in excess of $10,000 and to other HHAs, upon request, that have incurred financial hardship.

Outlier payments are subject to a 10 percent per HHAs per calendar year cap. The cap is enforced through comparing total outlier payments to total overall payments for each agency on a per claim basis. To reflect late submission of claims, a quarterly reconciliation adjusts claims to pay any outliers due or to recover overpayments.

The maintainer of the FISS has identified the problem and corrected software is being put into production starting May 29, 2013. The May 2013 outlier reconciliation will be re-processed in the near future. The adjustments will restore outlier amounts and the withholding/netting function will recoup the lump sum payments.

To review the complete information from your own MAC please visit their Websites listed below:

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