Home Health & Hospice Week

Home health agencies continue to hold out hope that the Centers for Medicare & Medicaid Services will play fair and give agencies the extra funds they are entitled to when they made M0175 mistakes to their own detriment.

But if CMS won't, the National Association for Home Care and Hospice is readying a lawsuit, says William Dombi, vice president for law with NAHC's Center for Health Care Law. "I believe CMS has the legal responsibility to make correct payments, not simply to confine its efforts to identifying and recovering overpayments," Dombi tells Eli.

The suit also will focus on timeliness of the recoveries, Dombi says. In OASIS item M0175, HHAs lose money if they leave off a skilled nursing facility or rehab stay in addition to marking a hospital stay that occurred within 14 days of admission.

"CMS's decision not to do the positive adjustments is out of character with the traditions of Medicare going all the way back to its roots in Social Security," insists Bob Wardwell with the Visiting Nurse Associations of America.

"Paying claims is not supposed to be adversarial, the goal is to pay the right amount," says Wardwell, a former CMS top official. "I was very proud to be part of a government organization that had a tradition of paying exactly what we were supposed to even if took extra work to do so."

It is "blatant unfairness" to downcode claims for M0175 mistakes, but not upcode them accordingly as well, criticizes Abilene, TX-based consultant Bobby Dusek.

And Dusek wants to see an analysis of how much money Medicare gained from M0175 mistakes in the time period studied by the HHS Office of Inspector General (see story, this page). Rural agencies especially have a hard time figuring out when patients have been in a SNF or rehab facility in addition to a hospital, mainly due to rural facilities' swing beds. In a swing bed facility, patients can stay in the same bed but switch from hospital to SNF or rehab status, he notes.