PEP adjustments on closed/purged patients
Several agencies have encountered the situation where a Medicare payment is being reversed and repaid on a patient who has already been discharged, zeroed out, and their admission and/or patient information purged from PROMISE. Many of you routinely purge closed patient records from the system as part of your yearend procedure, and with no way of predicting that Medicare would go years in the past to adjust claims, you certainly had no reason not to do that at the end of the past few fiscal years.
Whether you are posting payments manually or with Horizon's Medicare ERA software, you will not be able to enter the recoupment and repayment into your accounts receivable against a patient whose information you've purged. You'll get an "invalid patient" message if the patient has been completely purged or a "no admission" message if the Medicare admission for the time period of the adjusted claim has been purged.
In order to enter the revised payment on purged patients/admissions, you will need to re-enter the patient's information into PROMISE. This is straightforward for the patient demographics portion; for the admission, however, it may be a little trickier. You'll need to leave the admission number blank to let the system create a new admission, then key the admission information and save it. The new admission number may not be the one that was in effect for the claim you'll be adjusting - and it will need to be the same in order for the amounts to match up. To correct this, use the Reassign Patient Number function under Patient Registration/Patient Master. Key the patient number and the newly-created admission number at the top, and the same patient number and the intended admission number at the bottom. You will find the intended admission number on the RA as part of the patient control number and the medical record number, after the dash, such as 990123-02.
After you've recreated the patient and admission data that was missing, you can post the payments that were previously rejected. With Medicare ERA automatic posting, you will have the guidance of the posting log to inform you which patients are missing from PROMISE; with manual posting, you will just find them as you attempt to key the payments. With either method, you should use the same transaction scratchpad for both the originally-accepted payments and the ones you key manually after recreating the patient data, so the total RA is included in the same scratchpad listing. This is the easiest way to know if your posted payments match the remittance advice.
Tracking PEP adjustment amounts
It would certainly be nice if there were a way to identify the PEP takebacks and know how much and for which patients Medicare has recouped. We've looked long and hard at the data in the electronic remittance and unfortunately there are no reason codes or remarks being reported by Medicare that distinguish these recoup/repay pairs from any other type of Medicare payment correction.
Back at the beginning of PPS, we anticipated being able to identify PEP's on the RA and therefore set up an adjustment reason code 779 in PROMISE for that purpose. At the present time, however, there is not sufficient information being passed from Medicare in the remittance for the automatic posting system to tell the difference between a PEP adjustment, an A to B shift, or any other internal Medicare adjustment that shows up as a 328/32G or 338/33G pair. Therefore, the electronic posting program will create transactions with the standard adjustment reason 26 for recoupment.
If you are so inclined, you may certainly look over your RA's to identify the recoupments, decide if they are PEP takeback adjustments, and edit the adjustment reasons in the the corresponding scratchpad transactions. Changing the adjustment reason on these from 26 to 779 (or posting them that way to begin with manually) will give you an easy way to look back and see which patient accounts were adjusted as PEPs and when they were adjusted.
The "how much they've taken back" is more elusive. The A/R Recap will only be able to show the net impact of all the various payments and recoupments. The amounts of the 779 recoupments, if you've chosen to use that adjustment code, will only tell you the total charges that were taken back without considering the contractual adjustments. Since the billed charges are typically a "wash" in the takeback/repay pair reported on the RA, the real number that matters is the difference between the original contractual adjustment and the newly-paid contractual adjustment. This amount is evident as a positive number on a per-patient/claim basis on the scratchpad listing if the recoup and repayment were posted together, as the CASH AMT for the patient. (After you correct the erroneous contractual amounts on the 32G/33G repayments if posted electronically).
If you want to keep up with the running amount that Medicare has taken back for the PEP adjustments, your best bet may be to create a spreadsheet and log the per-patient/claim net amounts for PEP's from the scratchpad listings.
We'll stay on the lookout for ways to help track and report the PEP adjustments and pass along any useful tips that we can find.
Users of Medicare Automatic Remittance Posting
Some of you have recently encountered problems posting the RAs that include these PEP adjustments. The reason is that there are problems with the data being sent from Medicare/PGBA -- the contractual adjustment amount is incorrect for the repayment part of the PEP takeback.
From what we've seen so far, there is an obvious discrepancy between the contractual adjustment on the hard copy RA that is mailed out and the electronic RA that is downloaded, on the repayment portion of the PEP takeback. The PROMISE system can only post what it gets from PGBA in the downloaded file, and what they're sending us is WRONG!!
You will be able to identify the errors in the data in one of two ways:
What should you do if you have this problem?
First, call the Medicare EDI help desk and tell them that the contractual adjustments in your electronic remits don't match your hard copy remits on 33G claims for PEP repayments. Hopefully they've already been notified of this issue, but it won't hurt to tell them again.
Then, before you consider deleting the scratchpad and posting the RA manually (very difficult particularly since you've gotten used to having them posted for you), try making changes to the scratchpad that the system created. The best thing to do will be to edit the contractual adjustment transaction for each of the 32G or 33G claims on the RA. Change the amount on these transactions to reflect the correct contractual adjustment that you get from either 1) looking at the hard copy RA that you received in the mail, or 2) calculating the difference between the reported charges and the net reimbursement. You shouldn't have to do anything to the recoupment portion that shows up as a 328 or 338 claim on the RA.
After you edit all the patient-claim-specific contractuals for the 33G's, re-run the scratchpad listing and see if the totals are better.