Periodic Interim Payment (PIP) Eligibility
The periodic interim payment (PIP) method of reimbursement is available for the following services:
- Part A inpatient hospital services
- Part A skilled nursing facility services
- Part A hospice services
- Part A Critical Access Hospital (CAH) services effective July 1, 2004. (CMS has not yet issued implementing instructions for CAHs seeking interim payments under the PIP method).
Effective October 1, 2000 Home Health Agencies (HHAs) can no longer be reimbursed under the PIP method. A provider requesting the PIP method of reimbursement must have the continuing capability of maintaining in its records cost, charge, and statistical data needed to complete a Medicare cost report accurately and on a timely basis. (Refer to CMS Pub. 15-1, Section 2407). The provider must also have repaid or agree to repay any outstanding Medicare overpayments in full before they may convert from a regular interim payment method to the PIP method. Our approval of a provider's request for reimbursement under the PIP method will be conditioned upon our best judgement. We must be assured payment can be made to the provider under the PIP method, without undue risk of it resulting in an overpayment because of greatly varying or substantially declining utilization, inadequate billing practices, or other circumstances.
Providers have a responsibility to ensure they meet and continue to meet the requirements to remain on PIP. Providers receiving PIP must continue to meet all criteria necessary to begin receiving PIP payments, otherwise WPS must terminate the provider's option to receive interim payments under the PIP method. Any one of the following conditions may result in denial of or removal from the PIP method of reimbursement:
- The provider develops a pattern of filing untimely PIP reports or form CMS-91 (or substitute forms for PPS providers), meaning the provider files untimely for two consecutive PIP periods. Hospitals subject to the prospective payment system (PPS) are required to file a PIP report within 30 days after the end of the first and third quarters of their cost reporting period. PPS hospitals may request to file PIP reports for two different quarters if the first and third quarters are not feasible. All other providers must file PIP reports within 30 days after each quarter.
- There are consistent overpayments resulting from PIP reviews, indicating a provider is not self-monitoring their PIP payments.
- The provider does not promptly report payment discrepancies to the Fiscal Intermediary. Examples of payment discrepancies include receiving both Part A claims payments and PIP payments, or the bi-weekly PIP payment does not agree with latest completed PIP review. Prompt reporting is considered 30 days or less. Providers should be self-monitoring their PIP payments, including a full review of the remittance advice, and discrepancies should be reported immediately following the receipt of their bi-weekly PIP payment.
- Part A overpayments resulting from a Notice of Program Reimbursement, which exceed two percent of total Part A reimbursement, occur in two consecutive fiscal periods.
- More than 15 percent of the provider's claims are filed unclean or beyond 30 days after the discharge or service dates on the claims (refer to CMS Pub. 100-04, Chapter 1, Section 80.4).
- The provider requires an installment plan greater than twelve months to repay a Medicare overpayment or, within a five-year period, the provider requires two or more installment plans of any length to repay a Medicare overpayment.
The above noted events are considered sufficient cause to deny or terminate a provider from the PIP method of reimbursement. The above noted events are not an all-inclusive list.
Providers electing the PIP method of reimbursement are reminded that PIP payments are merely the best estimate of claims payment using the best data available at the time of the PIP review. Requests for revised PIP reviews should be limited to material, clear and obvious errors.
If you have any questions or comments, please contact the Audit Supervisor assigned to your facility, or refer to our Home Office Contacts.
Page Last Updated: Wednesday, 31-Dec-2008 10:49:09 CST
