Home Health & Hospice Week

Sixty-five percent of claims reviewed by OIG flunk OASIS edit.

Do you think you’d have no trouble getting paid by Medicare if CMS institutes tougher edits checking OASIS data? You may need to think again.

In October 2012, the Centers for Medicare & Medicaid Services implemented edits crosschecking inpatient rehab facility claims against their submitted assessment data (see Eli’s HCW, Vol. XXI, No. 39). CMS planned to implement similar edits for home health agencies, cross-checking HIPPS codes on claims against accepted OASIS data, in April 2014, according to a new report from the HHS Office of Inspector General.

CMS hasn’t followed through on the plan yet, which appears to be fortunate for HHAs. Of the 100 claims that the OIG sampled from 2010, the majority didn’t pass muster. The intermediary made payments totaling $157,000 for 65 claims “that should not have been paid because the HHAs had not submitted accepted OASIS data,” the watchdog agency says in a new report.

The OIG estimates that “the RHHI made $25.1 million in Medicare overpayments because it did not deny claims that HHAs had submitted without the required OASIS data, which is a condition of payment,” the report says.

The OIG urges CMS to “consider reopening the … 3,819 claims were paid before OASIS data were accepted and 12,663 [that] did not match to OASIS data … and recover any overpayments.”

Should You Expect OASIS-RelatedTakebacks Ahead?

In its response to the report, CMS agrees to “conduct an analysis based on contractor resources to determine an appropriate number of claims to review. CMS will instruct the contractor to review the claims and take appropriate action.”

The OIG also wants CMS to “encourage RHHIs to conduct periodic postpayment reviews of HHA claims, which would include ensuring OASIS data supports claims, until sufficient prepayment controls are established.”

Fortunately, CMS pushes back on this advice. CMS does not concur with this recommendation. “MACs are already reviewing HHA claims on a prepayment basis at this time,” CMS points out in its response. “Furthermore, enhancements are being made to the Medicare Contractors Extract Systems, such as adding more data fields to increase the probability of locating the OASIS.”

Watch out: “The OIG is taking a hardline approach in these audits and a similar approach would be expected of Medicare contractors, particularly RACs and ZPICs,” warns the National Association for Home Care & Hospice. “The OIG rarely gives up in these types of matters and the Medicare contractors often pursue any possible overpayments.”

Do this: HHAs should “evaluate their claim submission systems to ensure that claims are not prematurely submitted prior to the OASIS acceptance,” NAHC advises in its member newsletter.

This is an item agencies may be overlooking in their prebilling audits, since it doesn’t often affect claims payment, cautions billing expert M. Aaron Little with BKD in Springfield, Mo.

Beware this risk area: Sometimes an agency may inadvertently go for a period without submitting their OASIS due to turnover, Little points out. “Someone forgets to tell the newbie that it’s a function that’s part of their new job responsibilities.”

Note: The report is at http://oig.hhs.gov/oas/reports/region1/11200508.pdf.