Change in Payor source

We have a couple situations that we have never encountered. First we have a patient that had Medicaid then changed to a Medicare Advantage Plan and then we have a Medicare patient that changed to a Medicare Advantage plan. We do collect OASIS data on all patients so we have HIPPS codes etc but we are getting fatal audits when we go to export to the billing software. Should we have done a SCIC? Or what should we have done? Help


  • edited May 2017
    The MediCaid to Medicare Advantage might be looking for a SOC episode if they pay episodically.

    The same could be true of the other. Check with your billing software vendor.

    SCIC's related to payment no longer exist. A follow-up assessment is for a change in condition, not a change in payer.

    Susan G. Johnsen, RN, MSN, COS-C
    Director, Patient Care. LLUMC Home Health Care
    ph: 909 558 3285

  • edited May 2017
    Most anytime you have a payer change, the safest thing to do is "discharge" the patient in your software and create a new episode under the new payer. You can create a SOC OASIS based on current patient status. There has been guidance from CMS at some point in the past regarding this issue but could not tell you where to find it.

    Pamela Hall

  • This happens to us all the time. When the payer changes to Medicare (advantage or traditional) or from one Medicare plan to another you will need to bill with a new episode. Close the previous episode as of the last billable visit prior to the change. Have the clinician (hopefully a RN or PT) who made the very first visit in the month of the plan change do the soc oasis. You will need to generate a new plan if care and so on. We include a section on the plan of care indicating Pts insurance plan changed requiring a new plan of care (hence a new cert period). It's a pain to do all this but the only way we have found to be paid correctly.

    Melody Ford RN BSN CRNI
    Director of Clinical Services, Owner
    ABF Home Health Services, LLC
    P: 586-477-1402
    F: 586-477-1413

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