Outpatient PT & In-Home Health Medicare Issues

If you are in an outpatient PT clinic you know all to well the issues surrounding Medicare payments for patients who received outpatient PT as well as In Home Health services. To be completely honest . . . working these issues out is no walk in the park but I do have some advice on how to avoid it as best you can and how to get through receiving that dreaded Medicare refund letter.

It starts with the Patient Care Coordinators – All patients who have Medicare need to be asked a couple of VERY important questions.

1)     Have you received any In Home Health within the last 3 months?

2)     If the answer is yes – Who did you receive the services from? A name and phone number is required.

3)     When were you discharged or when does the In Home Health PT plan to discharge?

Once you receive the Home Health Agency contact information, call them and let them know that the patient is scheduled for Outpatient PT and ask for the official discharge date. Be sure to document everything so you can refer back to it in case the Home Health Agency discharges on a later date than originally planned.

If you follow those procedures, then the chances of you running into trouble are slim . . . but (and that’s a big but) there is still a chance that even after doing your due diligence, you still receive that ever so depressing letter from Medicare.

So what happened? Asking the important questions, don’t always result in the correct answer. I have experience multiple times, a patient who tells me that they don’t have anyone coming to their house nor did they EVER have someone come to their house. Unfortunately, some patients don’t have a memory that can be trusted.

What now? First things first, you must refund the Medicare amount immediately. Medicare doesn’t mess around and they WILL offset other accounts which is not fun for the billing department to figure out. Next, find out who the In Home Health agency is (if you haven’t already) and give them a call. Let them know the situation and most of the time, they find that it’s an error on their end. They need to adjust their discharge date and submit the changes to Medicare. Once that has been processed and completed on Medicare’s end then you can rebill the claim that was refunded.

DO NOT make the mistake of trying to get it all fixed before you send the refund check. Medicare doesn’t work that way. Once a refund request letter is issued, it MUST be paid. And if for some reason they don’t offset another account, they WILL send you to collections . . . quickly.

Another scenario, which is worse than the first, is that the patient actually DID receive In Home Health and out patient PT at the same time. In this case, you can actually send a bill to the In Home Health Agency. Per Medicare Guidelines, they are responsible for payment of part B services while a patient is under their treatment plan. Here is the Guideline listed on the Medicare Website, Section 10.11, Part C, Last Paragraph:

This one is tough because most In Home Health Agencies are not quick to cut you a check, even when referencing the Medicare Guidelines. My only suggestion if this occurs is don’t give up and keep trying.

It looks like there is a small light at the end of the tunnel . . . Per PTPN many of you have this issue and survey results were given to the APTA who is discussing this with CMS. CMS now wants the ICN claim numbers for instances when you received claim denials because the beneficiary was under a home health plan of care (even though you checked online, and asked the patient whether they were receiving home health, and all evidence pointed to no.)

CMS can use the claim number to look at the system and examine how long it took the home healthcare agency to submit a claim to CMS, indicating the beneficiary was under their care (which then impacts how quickly the system is updated). This information will be useful as CMS examines whether it should start requiring agencies to submit a “notice of admission” or other type of notice within a certain number of days after the beneficiary is admitted.

As always when working with Medicare, it will take time but steps are being taken to alleviate this issue.