Don’t know what PEP is? A PEP is a Partial Episode Payment that occurs when a patient changes agencies during the initial 60 day episode of care; or when a discharged patient during the original 60 days episode of care returns to home health. This event has financial implications for the primary agency, and results in partial loss of the HHRG payment. Instead of a full payment, the primary agency receives an adjusted payment for the time the beneficiary was on service. For purposes of this article, we will focus on the PEP’s that occur when 2 agencies are involved, and we will examine the practices surrounding these situations that have affected the industry.
One of the most important steps in Home Health billing relates to the admission process. All agencies are to verify current patient status in the Common Working File (CWF) upon admission. This is not an OPTIONAL step. If the patient is in a current episode of care with another provider, you must notify the primary agency of the intended transfer. Under the Home Health Prospective Payment System (HH PPS), beneficiaries who meet eligibility requirements, may decide to transfer from one home health agency to another as many times as they would like. With this being said, all beneficiaries involved in a Beneficiary Elected Home Health Transfer MUST be notified by the receiving agency that the initial HHA will no longer receive payment on their behalf and will no longer service them. Patients in this situation always have a choice of what provider they use; the initial question regarding any prospective patient transfer; Is this the patient’s choice?
A more common type of PEP occurs when a patient, already discharged from the primary agency, has an intervening event; i.e. new diagnosis, hospitalization, or change in condition, that would make them eligible for the home health benefit again. It is the beneficiary’s decision whether to return to their previous agency, or choose to go to another that they select for whatever reason. Again, this decision belongs to the beneficiary alone. If they decide to choose another agency, based on their choice alone, the receiving agency must follow the Beneficiary Elected Home Health Transfer regulations.
Receiving Agency:
1. Contact the agency and WORK out a transfer date
2. DOCUMENT that you contacted them, include name, date and time
3. The beneficiary must have been informed that the original agency will no longer receive payment on their behalf and will no longer service them. Beneficiaries have a choice, is this theirs? DOCUMENT IT.
Primary/Original/Transferring Agency:
1. DOCUMENT that the agency contacted you, and that you accept the transfer
2. Include the name of the person you spoke with, the date and time
3. Close out your case, and SUBMIT THE FINAL CLAIM.
If any dispute occurs between agencies, then the MAC (Medicare Administrative Contractor) may become involved to settle the dispute. If the beneficiary decides to change agencies, and or there has been an intervening event during this original 60 day episode that justifies another episode of home care, there should be no problems or issues in this transfer. Some practices associated with this process heard around the nation include:
1. The primary agency willfully will not discharge the beneficiary stating “ownership” of the patient. Often times, names, fax numbers or pertinent information in the transfer process are willfully withheld to stall the transfer. This abusive practice should be reported to the Fiscal Intermediary when it occurs; no beneficiary is the “property” of any agency.
2. The receiving agency does not notify the original agency. The process of Home Health Transfers is clear, concise, and is the responsibility of both agencies to work together to complete. Every agency should adhere to the rules and processes, and should incorporate this into their compliance plan for billing. It is not OPTIONAL to notify the primary agency. It is most importantly the responsibility of the receiving agency to notify and DOCUMENT the transfer process. It is required that all agencies comply with these rules, and it is not appropriate to bill if you have NOT followed the “receiving home health agency responsibilities”. You must maintain clear records of the notification if a dispute should evolve. Occasionally, disputes arise when the receiving agency does not notify the original agency, or states “we forgot”. It is not an option to forget this process; there can only be one primary agency submitting at a time.
In some PEP instances, patients are provided reasonable and necessary care by the original agency. When the POC is completed, goals are achieved, and the beneficiary has reached maximum potential, the patient, in accordance with the rules, is discharged from service before the end of the 60 days. For whatever reason, the patient is seeking admission to a second agency. In checking the CWF on admission, if the patient is current with the primary agency, you need to follow the process and notify them of the transfer. The CWF episode may not be closed despite the patient being discharged. In these types of events; important questions in the acceptance of referrals would be: “Why does the patient require another episode of home health care if they just finished one? Was there a change in condition? New diagnosis? Recent hospitalization?” It is important to ask questions, and ensure eligibility of all beneficiaries being admitted to the agency. Work with your admission clinicians to ensure that eligibility requirements are being met. Practices NOT associated with this include:
1. A beneficiary may meet another nurse at the senior center, through friends/family, etc and sign up for services because they “like” the nurse. There is no eligibility here. If the patient has been discharged appropriately from the primary agency, then what is the skill of a second episode? Federal monies paid into this program were not for these purposes; refer to the Medicare Benefit Policy Manual Chapter 7 number 30. Tax payer money funds this program, and should be spent on care that is in compliance with all State and Federal rules and guidelines.
2. Knocking on doors, “combing” for patients, and offering a “stop by and check in on you service”. The Home Health Benefit was never intended to “stop by and check in on you”. Beneficiaries have these programs presented to patients as a “free” service, so why not? This is not qualified and skilled care. If the beneficiary does not qualify for service, they are not to receive the “free” benefit. Family, friends and neighbors can “stop by and check in”, this is not reasonable, necessary, or skilled homecare.
Please refer to your own MAC for regulations, dispute forms, and further guidance. In practices surrounding PEP’s, the rules are clear. Billing practice, agency culture, and ethical practice are imperative. Consider the basics of The Medicare Benefit Policy Manual Chapter 7, Section 30: Conditions Patients Must Meet to Qualify for Coverage of Home Health Services, and ponder the requirements. Are the clinical, billing, and management staff well trained on rules, regulations and processes of PEPs? Compliance is key for qualification in PEP scenarios.
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Consultant of HHSM. Her expertise is based on sixteen years of homecare experience.