How to bill Medicare Advantage plans in home health and hospice

Given their increasing popularity, it’s likely that MA plans are here to stay. So, it’s important to understand and get ahead of the reimbursement challenges they pose for home health and hospice agencies:

• Notice of Admissions (NOA): Starting January 1, 2022, Original Medicare guidelines required home health agencies submit NOA within five days from the start of care. But private MA payors provided no such direction, leaving many agencies struggling to obtain final payment when NOAs weren’t in place within the five-day rule.
• Health Insurance Prospective Payment System (HIPPS) rate codes: These codes represent specific sets of patient characteristics payors use to make payment determinations during claims processing. This is typically documented as part of the OASIS process. Original Medicare can access the state database where OASIS HIPPS codes are stored to determine validity during final claims processing. MA payors don’t have access to this database and can’t see the actual OASIS HIPPS, so they pay using the generic HIPPS which often results in underpayment to home health and hospice agencies.
• Appeals and recoupments: Original Medicare has a 14-day turnaround from the time you submit a final, accurate claim. This ensures agencies receive proper, timely payment and aren’t underpaid. But with the frequency of underpayment from private MA payors, agencies must appeal to receive full payment for services. In the case of recoupment, private payors often require the patient’s full medical record for review, which takes time and further delays full payment to the agency.
• Authorizations: One of the biggest differences between Original Medicare and Medicare Advantage is authorization. Original Medicare doesn’t require authorization, but most MA payors require agencies to obtain authorization before treating the patient. This often results in reduced payment — or in some cases no payment — when authorizations aren’t obtained upfront. In this case, agencies can appeal for medical necessity but again, it will likely take time to get your money.