OASIS Alert

Published on Tue Sep 06, 2005 PDF

Your intermediary has a holiday present for you.

If you were dreaming the M0175-induced recoupments were just going to go away, it's time to wake up and smell the coffee.

The Centers for Medicare & Medicaid Services has instructed regional home health intermediaries to begin making M0175 adjustments--both recoupments and payments--in November, CMS official WilGehne announced in the Aug. 25 Home Health, Hospice and DME Open Door Forum.

Problem: For the first three years under the prospective payment system, the claims processing system didn't catch mistakes if an agency failed to mark a hospital, skilled nursing facility, or rehab stay in OASIS item M0175.

When agencies omitted a hospital stay, but checked a SNF or rehab stay, they received $200 to $600 too much in reimbursement for that episode. On the other hand, if they failed to mark a SNF or rehab stay that occurred with no hospital stay, they received $200 to $600 too little for that episode.

The HHS Office of Inspector General reported its projection of millions of dollars in overpayments resulting from missed hospital stays. The home health industry countered with the possibility of a similar amount of underpayment from missed SNF or rehab stays. The resulting discussions and system adjustments delayed the process of correcting these errors.

The RHHIs now have the files needed to begin the process, CMS says. Beginning Oct. 24, intermediaries will post the over- and underpayments on the system so that agencies have five weeks to review them for accuracy. Adjustments will begin the week of Nov. 28.

"The impact of these adjustments on home health agency cash flow isn't expected to be significant," Gehne said in the forum. That's partly due to the over- and underpayments offsetting each other. "If people have findings to the contrary of that, then we certainly want to know about them," he said.

The files will include adjustments based on patient stays in long-term care hospitals,Gehne confirmed. That's despite industry protests that LTCHs function more like SNFs than acute hospitals.

What to do next: Once the RHHI posts the proposed adjustments, agencies should check those for errors. If the HHA finds an error, notify the RHHI, a CMS spokesperson instructed forum listeners. If the intermediary agrees with the error, it will remove the adjustment. Once the adjustment is made, the agency must use the claims appeals process for corrections.

Note: For the latest news about the changing claims appeal process, subscribe to Eli's Home Care Week at www.elihealthcare.com or by calling (800) 874-9180.