NAHC Working to Resolve Issues with Outlier Payments

The National Association for Home Care and Hospice made its first report to the Centers for Medicare & Medicaid Services (CMS) of errors in home health outlier calculations early in 2010. CMS acknowledged and began investigation of the problem, which was related to the newly imposed outlier cap calculation. CMS’ attempts to fix the problem in October 2011, and January, May and July 2012 were unsuccessful.

As a result, many home agencies did not receive full outlier payments for the years 2010, 2011 and 2012, with underpayments ranging from tens of thousands of dollars by small agencies to millions by large agencies. In its efforts to seek a solution to this problem, NAHC wrote to the CMS Acting Administrator on June 21 – and again after the failure of the July fix – requesting her assistance in an immediate resolution. In response, the Acting Administrator directed CMS staff to resolve the problem as quickly as possible and agencies across the country finally began to receive the money owed them beginning in August.

On May 13, 2013 NAHC began receiving phone calls from home health agencies about a new problem with their 2010 and 2011 outlier payments. These agencies reported that they received notification from their MAC that they had been overpaid for 2010 and 2011 outliers and that the overpayment recoupment would begin the next day. These are the same agencies whose two-three year outstanding outlier underpayments were finally resolved last summer.

The error appears to be the result of underreporting of total revenue calculations by the MAC for the years in question, placing agencies over the 10 percent outlier cap. For example, one agency with $17m revenue was reported with revenue of $4.5m, thus ineligible for any outlier payment beyond $4.5m being subject to overpayment recovery. This error appears to have been triggered by the quarterly outlier adjustments.

NAHC took immediate action, notifying both the MAC and CMS. NAHC advised them that, “The situation is critical for these home health agencies” requesting action to stop and reverse the overpayment recoupment while this problem is investigated and resolved. Both CMS and the MAC responded, promising to look into the outlier situation immediately. NAHC will provide updates as new information becomes available.

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