OASIS Alert

Published on Sat Oct 14, 2006 PDF

One-year delay is about to end.

Agencies are facing a per-episode recoupment of $200 to $600 for fiscal year 2001 claims in which M0175 wrongly showed a skilled nursing facility or rehab stay without a hospital discharge within the same period.

After a year of work to be sure the M0175 recoupment process complies with the requirements of the Medicare Modernization Act, the Centers for Medicare & Medicaid Services is ready to try again. In Transmittal No. 1079, released Oct. 20, CMS details the process fiscal intermediaries will use to recover the overpayments, beginning Jan. 18, 2007.

The basics: M0175 asks about prior inpatient stays within the 14 days before the admission assessment. If the answer shows a skilled nursing facility or rehab stay without a hospital discharge within that time period, the agency's reimbursement for that episode increases by $600 for a high-therapy-use patient and $200 without the therapy. So if agencies noted the SNF/rehab stay but missed the hospital stay, they were overpaid. If they missed the SNF/rehab stay and there was no hospital stay, they were underpaid.

CMS suspended the adjustment process in November 2005, when the National Association for Home Care & Hospice pointed out potential legal problems with the recoupment process the government intended to use.

What next? The change request outlines the notification and appeals process available to agencies that want to challenge the overpayment determination. Look for a provider education article at www.cms.hhs.gov/MLN MattersArticles, CMS says.
 
At an unspecified later date, CMS plans to identify and recover M0175 adjustments for fiscal year 2002 and later years.

Don't overlook: Take time to verify the accuracy of the claims the intermediary identifies as overpayments, says Ft. Lauderdale-based consultant Susan Justice-Moran with Justice-Moran & Associates.

Check the prior stay information against the Common Working File, using the "APP Date" field on the HIQA/ELGA CWF inquiry screen, instructs consultant M. Aaron Little with BKD in Springfield, MO. "This option allows providers to view hospital and SNF inpatient stay information from past periods," he tells Eli.

But don't make the mistake of assuming the CWF is always right. "Because the CWF data is based on provider claims data, there is certainly the possibility for errors," Little notes. If you have conflicting information, you can follow up with your own detective work, including speaking to the institution that billed the prior stay. 

Note: For a copy of the detailed Transmittal 1079, e-mail marianc@eliresearch.com, with TM1079 in the subject line.