Audit of CHHA EPS

On Feb. 10^th, the Department of Health (DOH) posted a Dear Provider letter outlining the recent audit finding on the CHHA Episodic Payment System (EPS) by the Office of the State Comptroller (OSC). OSC found Medicaid overpayments to a number of CHHA providers, due to claim submissions which resulted in inaccurate payments when billing for partial episodes paid as full episodes. OSC has referred their findings to the Office of the Medicaid Inspector General (OMIG) for appropriate recoupment action.

As outlined in the letter, the overpayments fall into three major categories:

1. Providers receiving a full payment for a partial episode, when that provider subsequently initiated a new episode for the patient within 60 days of the beginning of the first episode; resulting in duplicate payment to the CHHA.

2. Providers receiving a full payment for a partial episode when the patient was subsequently enrolled in a managed long term care (MLTC) plan within 60 days of the beginning of the episode; resulting in overlapping payments. These situations could be the result of an erroneous discharge code submitted by the CHHA when the patient is discharged directly to MLTC or they could be an inadvertent situation when the patient is discharged to a non-LTC setting, but subsequently enrolls in an MLTC within 60 days of the beginning of the episode.

3. Providers receiving a full payment for a partial episode when the patient subsequently is admitted to another CHHA within 60 days of the beginning of the episode. These situations could be an erroneous discharge code by the CHHA when the patient is discharged directly to the other CHHA or inadvertent when the patient is discharged to home or a hospital, but subsequently is admitted to the second CHHA within 60 days of the beginning of the episode.

According to the provider letter, it is the responsibility of DOH and Medicaid providers to ensure that there is no duplicate or overlapping payments for Medicaid services; all the overpayments identified by OSC as contrary to the EPS billing rules must be corrected through OMIG audit adjustment.

The OSC report indicates that the majority of the overpayments were in fact based on:

1. Erroneous discharge codes used by a CHHA providing multiple episodes to the same patient; or

2. An erroneous discharge code used by a CHHA for a patient who was discharged directly to a managed long term care plan.

DOH has directed CHHAs to refer to the Billing Guidelines dated April 9, 2013, for these types of errors are within the control of those submitting claims. The provider letter outlines codes and details on Full and Partial Episodes. CHHA providers are strongly encouraged to check their billing systems to ensure that they are in compliance with the billing rule requirements for partial episodes.

Information regarding CHHA rates, CHHA billing questions, and other CHHA related issues may be found at http://www.health.ny.gov/facilities/long_term_care/reimbursement/chha/.

Specific questions regarding this audit can be sent to DOH at BLTCR-CH@health.ny.gov.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871