TPL Resource Page

HCA's TPL Resource Page provides information to providers on new billing requirements that stem from the expiration of the Third Party Liability (TPL) Demonstration Program at the federal level.

HCA is continuing our strenuous advocacy with New York's Congressional Delegation and the U.S. Centers for Medicare and Medicaid Services (CMS) to restore the Demo, a fair and efficient program for reconciling Medicare/Medicaid claims for dual-eligible patients.

Absent reauthorization of the Demo, the state Office of the Medicaid Inspector General (OMIG), however, is now requiring agencies to demand bill Medicare for certain past claims as a way of determining payment responsibility for cases in the 2007 federal fiscal year.

The following links contain more information on that process. Please also review HCA's most recent editions of ASAP for more information on our advocacy as it relates to this issue.

»NGS's August 6-7 Demand Billing Conference Call — Q & A and Demand Bill Presentation

»TPL Question and Answer Document

»Additional Question and Answers from the OMIG

»New York's OASIS Coordinator: Maureen H. Duffy (518) 408-1658 oasis@health.state.ny.us

»CMS's Prospective Payment System (PPS) Grouper link to assist agencies in calculating a HHRG for demand bills (if your software system cannot do this): www.ppsgrouper.com.

Billing Recommendation from UMass, the OMIG's Contractor

During a recent conference call on demand billing, representatives from UMass, the OMIG's contractor for the demand-billing process, provided a recommendation (based on another provider's experience) concerning: i. which dates providers should include on the demand bill when the start of care, admission and certification dates are prior to October 1, 2007; and ii. which dates should be included when the first billable visit may be different than the certification date.

UMass's recommendation was based on the following scenario:

Home health agency X has successfully submitted a couple of RAPS and demand bills (final claims) in cases where the admission date was, for example,  05/01/2006, but the most recent certification period for the case was 09/08/2007, and the first visit for which they were being asked to bill Medicare was dated 10/01/2007.

HHA X went into FISS and created a RAP with an admission date of 05/01/2006 and an episode start date of 09/08/2007 that included a 0023 revenue code date of 10/01/2007. The RAP was processed and paid.

When HHA X submitted the demand bill (final claim), it only included visits from 10/01/2007 through the end of the episode — even though there were visits from 09/08/2007 through 09/30/2007.  HHA X did not include these visits as non-covered. HHA X's demand bill (final claim) was accepted without being denied, rejected or returned to provider (RTP'd). Of course the demand bill (final claim) was submitted with condition code 20, and all charges as non-covered.