OASIS Alert

Published on Fri Oct 01, 2004 PDF

Avoid mistakes in the 3 areas that plague most HHAs.

Time is running out. Payers may owe you thousands of dollars in underpaid episodes, but every day you delay makes the money harder to claim.

You have until Dec. 31 to find and correct mistakes on claims for episodes ending from October 2002 through September 2003, advises consultant Karen Crosby with the accounting firm Abraham & Gaffney in St. Johns, MI. There are three areas where agencies are especially likely to find errors, experts say:

1. Underpayments for episodes with 10 or more therapy visits. "We're encouraging agencies to start looking at this to allow time to correct claims, because we're still finding people are losing money on therapy claims errors," Crosby tells Eli.

If you don't understand how the claims process works for therapy visits, you could be throwing money away. If you answer "No" to M0825 on the OASIS assessment - predicting that the patient would not need 10 or more therapy visits - but then you provide at least 10 visits, your fiscal intermediary does not adjust payment for you. If the additional therapy resulted from an incorrect estimate - not from a significant change in condition - you can go back and correct the claim. This correction results in extra reimbursement averaging more than $2,000 per episode for high therapy use, Crosby says.

What to do: To correct an underestimation you must go back and change the answer to M0825 and resubmit the claim.

2. Uninvestigated therapy downcodes. Don't just accept M0825 downcodes, advises consultant Terry Cichon with FR&R Health-care Consulting in Deerfield, IL. Problems arise when an agency anticipates 10 or more therapy visits but submits the claim without 10 visits listed. Your FI will downcode this claim.

Tip: Keep in mind your FI would be glad to find that some of your therapy visits didn't count, because then it wouldn't have to pay you the higher rate. Investigate every therapy downcode to verify that it is valid; frequently an agency fails to bill legitimate therapy visits, Cichon says.

3. Incorrectly billed SCICs. Billing SCICs when you don't have to will cost you money, Cichon reports. The national average for SCICs includes all the SCICs billed in error, so your percentage should be lower, she counsels. If your agency has a higher percent of your episodes as SCICs, "there is a good probability that you are billing some in error," she predicts.

Do this: If you're concerned about the number of SCICs you're billing, first verify the process you follow (see story, article 2). If the pro-cess is incorrect, begin chart reviews to find lost revenue, Cichon recommends.

Smart idea: In any situation where you correct a claim in your favor, be sure to analyze the record carefully and document carefully, because the FI is likely to ask for additional documentation, Cichon adds.

Editor's Note: CMS' OASIS correction policy is at http://www.qtso.com/download/hha/HHAcorrectionpolicy.pdf.