Home Health & Hospice Week

CMS official reveals M0175 recovery schedule for early claims.

Just because you haven't seen M0175 takebacks yet doesn't mean you won't be hit with thousands of dollars in recoupments soon.

The Centers for Medicare & Medicaid Services is waiting on three more reports from the HHS Office of Inspector General before moving ahead with takebacks related to the OASIS item on prior inpatient stays, CMS said in the Feb. 18 Open Door Forum for home care providers.

CMS hopes to receive the reports, which will cover M0175 overpayments made in fiscal year 2001 by regional home health intermediaries Palmetto GBA, Cahaba GBA and United Government Services, in "the next month or so," it said.

The OIG already issued its report on Associated Hospital Service of Maine last July, when it estimated AHSM paid out $1.9 million incorrectly when home health agencies failed to mark a hospital stay in addition to a skilled nursing facility or rehab stay within 14 days of home health admission (see Eli's HCW, Vol. XII, No. 27).

Once it receives the remaining three OIG reports, CMS wants to go ahead with the takebacks for agencies served by all four RHHIs at the same time, an official said in the forum.

And this year HHAs get a special treat -- recoupment of M0175 for two different fiscal years. In addition to the FY 2001 takebacks tied to the OIG reports, CMS also will initiate recoupments for FY 2002 as soon as they've identified all the M0175 overpayments.

Medicare providers had until Dec. 31, 2003 to file their claims for FY 2002, a CMS official explains to Eli. "We're in the process of running that data now and expect to initiate the FY 2002 recoveries some time later this calendar year," the source says. "This will be the only time we recover two FYs in one calendar year."

CMS must wait until after Dec. 31, 2004 to identify M0175 overpayments for FY 2003, the official says. The resulting takebacks will occur in CY 2005, with annual recoveries following.

HHAs should be prepared for M0175 recoupments, since CMS issued instructions on them back in October, notes consultant Rick Ingber with ZA Consulting in Jenkintown, PA.

But in reality, most agencies aren't ready for the takebacks that CMS has estimated will be $4,000 per agency, notes consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. "They were hopeful that CMS would not be able to go back so far" to recoup payments, Boyd tells Eli. And "they do not know how much or how many of their claims will be affected," he adds.

Some HHAs will have to pay much more than $4,000 while others will be well under, depending upon their accuracy in answering M0175. CMS says it will make the recoupments all at once, unlike ongoing recoveries for partial episode payment (PEP) adjustments.

Many agencies may want to pay back the funds over time, Boyd notes. But it is unclear whether CMS will allow that.

Boyd hopes the recoupments will give agencies the incentive to go back to their prospective payment system OASIS and claims and secure funds they missed. HHAs served by reimbursement recovery specialists Abraham & Gaffney have missed as much as $250,000 due just to therapy billing mistakes, for example (see Eli's HCW, Vol. XII, No. 42).

"Most HHAs are overly cautious and conservative in completing their OASIS," Boyd observes. "Many of them are shortchanged Medicare monies as an result."

Boyd also hopes CMS, the Medicare Payment Advisory Commission and other government entities take M0175 and PEP adjustments into account when calculating HHAs' supposedly generous profit margins.

And industry representatives still haven't given up the fight for securing payment for M0175 mistakes in agencies' financial favor. Mary St. Pierre from the National Association for Home Care and Hospice urged CMS to engage in further discussions on the matter due to language passed in the Medicare reform bill in December.

Other issues raised in the forum: