OASIS Alert

Published on Thu Jul 08, 2004 PDF

Think you should send in only one OASIS? Think again.

CERT reviews are about to become more insistent, so plan now to get your claims right the first time.

The Centers for Medicare & Medicaid Services is applying pressure on contractors to improve the response rate to the Comprehensive Error Rate Testing Program (see story "Be Certain You Respond To This Letter"), so take those requests off the back burner.

"We [at NAHC] have great concern about the quality of the reviews and the reviewers of these CERT contractors," Mary St. Pierre emphasized at the National Home Care & Hospice Policy Conference in Washington in April. There have been many problems with CERT reviews, including erroneous denials of entire categories of claims, she warned agencies, and many of these have been reversed on appeal.

When you appeal a CERT contractor's decision to deny claims, the review of that decision is done by your FI, who may have already reviewed and paid the claim, she added. Respond to a CERT request just as carefully as you would to an additional development request (ADR), St. Pierre said. To succeed in the review or appeal you need to submit a complete and accurate record.

Protect yourself: St. Pierre offered these 10 tips for CERT success:

1. Respond promptly. Your records are due no later than 45 days after the request.

2. Include the complete record. Don't forget a cover sheet, an inventory of the items included and the original CERT request with the bar code. Highlight any information you think is important to make your case.

3. Cover the dates requested. Include the entire record for that time period. Remember visit notes, narrative notes, conference and communication notes and doctor's orders.

4. Send both current and prior OASIS. The earlier OASIS may provide support for areas they question.

5. Beware of M0175. If any of the requested records are for a patient who had a SNF or rehab stay and no hospital stay, before sending your response, check to see if you missed a hospital stay and reported the wrong HIPPS code. If so, correct it before it goes through medical review, and include a note pointing out that correction.

6. Focus on the record. Documentation to support therapy services and HIPPS code is especially important.

7. Identify possible problems. Provide supporting information, such as a supporting statement from the physician, supporting lab results or medical textbook information.

8. Secure the packet so pages aren't lost. Put each individual CERT request in a separate packet.

10. Send the documents to the right contractor. CERT contractors and FIs do not share information. And make sure the address is correct. Mail it "return receipt requested."