Hospice Claims Incorrectly Returned to Provider

NAHC

Some hospices are seeing claims Return to Provider (RTP) due to a problem with the attending physician’s National Provider Identifier (NPI).  Transmittal 11633/Change Request (CR) 12889 which instructs MACs to have an edit that validates the attending physician’s NPI includes hospice claims and should not.  The CR instructs MACs to validate the NPI in the Attending Physician field on a claim against the Provider Enrollment, Chain, and Ownership System (PECOS) file.  If the NPI is not found in the file, the claim will be returned to the provider.

However, attending physicians for hospice patients are not [yet] required to be PECOS enrolled so their NPI will not be in the PECOS file unless they are otherwise enrolled.  The FY 2024 hospice proposed rule includes a proposal that physicians certifying hospice care be PECOS enrolled or have a valid opt-out but that is not finalized.

Effective April 1, 2023 hospices that submit a claim where the attending physician’s NPI is not in the PECOS file, the NPI and last name do not match, or the claim has a date of service equal or greater than the termination date on the PECOS enrolled physician inquiry screen will see the claim RTP.  NAHC reached out to CMS about this issue and CMS confirmed that the edit is being applied inappropriately.

New instructions are being sent to the Medicare Administrative Contractors (MACs) to fix the issue.  A specific timeframe is not provided but CMS indicated the instructions should reach the MACs within 30 days and the MACs will then have ten business days to implement. However, PalmettoGBA has already posted to its website that within ten days (April 17, 2023) all hospice claims RTP’d due to a problem with the attending physician’s NPI will be returned to processing and there is no additional provider action necessary.

Any hospice claims impacted prior to the fix being implemented will need to resubmit the claim.  Hospice providers in other MAC jurisdictions should watch their MAC’s website and communication channels for more information.