Home Health & Hospice Week

One intermediary overpaid HHAs by $2 million in 2001 alone, based on incorrect OASIS responses.

It's not enough that home health agencies must withstand takebacks for partial episode payment adjustments (PEPs); now they should prepare for millions in recoveries due to inaccurate answers to OASIS item M0175.

That's what the HHS Office of Inspector General recommends in a new report examining the impact of incorrect responses to M0175, which asks about a patient's inpatient stays within 14 days of home health admission (A-01-03-00500).

The OIG examined a sample of 200 claims from fiscal year 2001 for which regional home health intermediary Associated Hospital Service of Maine paid a higher amount based on M0175. Out of those 200 claims, there was $77,461 in overpayments based on wrong responses, the OIG says. Extrapolated to the more than 6,000 higher-paying claims for that year based on M0175, AHS overpaid about $1.9 million based on the OASIS item, the watchdog agency estimates.

The overpayments come about when HHAs fail to mark all the correct responses to M0175. If they mark that the patient had a rehab or skilled nursing facility discharge without also marking that the patient had a hospital discharge in the 14-day time period, the episode receives an extra point in the service utilization domain.

That extra point bumps the HIPPS code up from a "J" or "L" in the fourth position to a "K" (without therapy) or "M" (with therapy), the OIG explains in the report. In two examples the OIG used, that results in an extra $200 for a non-therapy patient and an extra $600 for a therapy patient.

Agencies are marking M0175 incorrectly because they overlook the hospital discharge preceding the rehab or SNF discharge in the two-week period, or because they fail to gather accurate discharge data from the beneficiary, family member/caregiver or referral source, the OIG concludes.

Clinicians often are in a rush to complete the OASIS assessment while they are in the home, so they can get to the more clinical part of the visit, says OASIS expert Karen Vance, a consultant with BKD in Springfield, MO. That makes it easy to overlook two different discharges in the relevant time period.

But often it's nigh impossible to extract the correct information out of the beneficiary, caregiver or referral source, HHAs argue. "Patients don't make the best historians," agrees Vance.

"It is terribly hard in many cases to get reliable information from our patients and families," insists Bob Wardwell of the Visiting Nurse Associations of America. "Hospital referral staff are also overworked and difficult to reach."

Information mix-ups especially occur when the rehab or SNF facility a patient was admitted to actually was within the same hospital the patient was discharged from. The confusion increases even more if the patient was in a swing-bed hospital, where she doesn't even change rooms or beds when she goes from acute hospital inpatient stay to SNF stay status, notes consultant Rose Kimball with Med-Care Administrative Services in Dallas.

"I know my 'mom-n-pop' clients aren't making the distinction between a regular bed and a SNF bed" in swing-bed hospitals, Kimball laments. Swing-bed facilities predominate in rural areas.

Even the OIG admits obtaining accurate discharge information is difficult.

"The information sources available to HHAs ... cannot always be depended upon for accurate hospital discharge information," the OIG says in the report. Rehab and SNF facilities told OIG researchers they don't always include hospital discharge information in their own discharge summaries.

RHHIs' lack of edits on this issue hasn't helped the matter, Kimball maintains. If agencies knew they were billing incorrectly from the start of the prospective payment system, they could have taken corrective action. But they believe they are filling out OASIS correctly and receiving their rightful payment for the patient's episode.

"It always strikes me as counterproductive when auditors place blame for this kind of error on the 'little guy,' in this case a hard-working nurse, while CMS and its contractors have had all the information at their disposal to prevent the problem in the first place," criticizes Wardwell, a former CMS top official.

"Our VNA nurses deserve a pat on the back for providing great care to our patients, and going above and beyond to get OASIS done as well as they possibly can, instead of another kick in the pants for not achieving some mythical level of OASIS perfection," Wardwell fumes.

Wardwell calls on CMS to make hospital, rehab and SNF stay information easily available to HHAs so they can check the information before filling out OASIS, rather than sending agencies on a wild goose chase that may result in inaccuracies despite their best efforts. "It would be infinitely more fair for prior stay information to be made available to providers and used in edits rather than telling nurses to get busy on this, when they already are," he maintains.

Installing edits to catch incorrect M0175 responses is one recommendation the OIG makes to AHS to curb discharge-related overpayments. That means HHAs can expect increased medical review - and resulting recoupments - for "K" and "M" claims in the future.

The OIG also wants the RHHI to collect the $77,000 the OIG identified in overpayments, and go back, track down and collect the other $1.8 million in overpayments the OIG estimates for FY 2001.

AHS agreed with the OIG's conclusions and recommendations, the OIG says.

Wardwell notes that neither the OIG, CMS nor its contractors has made any effort to go back and increase payments where providers answered M0175 incorrectly to their financial detriment. "It's not too much to expect of CMS and its contractors, whose mission is correct payment of all claims," to identify underpayments as well as overpayments based on M0175 inaccuracies, he concludes.

This report is just the first of four, in which the OIG examines M0175 errors for all four RHHIs (see Eli's HCW, Vol. XII, No. 6, p. 44). That means more recoupment recommendations down the line for other regions. And those recoveries are likely to be even higher, since AHS is the smallest of the four RHHIs.