Home Health & Hospice Week

Adjustments for OASIS item on prior inpatient stays befuddle HHAs.

If you're scratching your head over the amount of your M0175 takebacks in the first year of the prospective payment system, you're not alone.

Regional home health intermediaries Cahaba GBA and United Government Services posted the fiscal year 2001 adjustments for the OASIS item on patients' prior inpatient stays by the Oct. 24 deadline set by the Centers for Medicare & Medicaid Services (see Eli's HCW, Vol. XIV, No. 39). But RHHIs Palmetto GBA and Associated Hospital Service of Maine failed to do so.

Palmetto remedied the situation by posting its adjustments Nov. 4. AHSM planned to post its adjustments by Nov. 7, according to the National Association for Home Care & Hospice.

But the Palmetto list excludes 2,500 adjustments that "could not be re-created at this time," the intermediary says in a posting on its Web site. "Once we receive the adjustments from the Data Center, we will contact the impacted providers."

Because HHAs are supposed to have a five-week window to view the M0175 upcodes and downcodes, Palmetto will begin processing the adjustments Dec. 9. Cahaba and UGS will begin their processing on the original deadline of Nov. 28, they say.

Adjustments Don't List Dollar Amounts

But having the M0175 adjustments posted isn't helping many agencies figure out what they're going to owe for their incorrect answers to this OASIS item in FY 2001. "There is no way to determine any dollar amounts with these adjustments until the claims actually process at the Common Working File," Palmetto warns in its posting. "Providers can only determine the number of upcoded adjustments versus downcoded adjustments."

Some agencies have developed spread sheets to identify the status of individual claims, recounts consultant Judy Adams with LarsonAllen Health Care Group based in Charlotte, NC. "However, this process takes hours of work and requires the agency to go back and find the records and try to recalculate the amounts owed or due to them," Adams points out.

Consultant Pam Warmack with Clinic Connections in Ruston, LA says many HHAs are just ignoring the M0175 adjustments altogether, rather than spending time trying to figure them out. "It has proven a daunting task that no one wants to take on," Warmack tells Eli.

Secure Ballpark Figure of Your M0175 Takebacks

There is a relatively quick and painless way for HHAs to determine the dollar impact of their M0175 adjustments, offers consultant M. Aaron Little with BKD in Springfield, MO:

1. Look at the billing code. HIPPS codes will be up- and downcoded for M0175 answers in J-K or L-M pairs, Little explains. If the suspended claim was billed with a HIPPS code ending in J, it's being upcoded to a K. If it was billed with a K, it's being downcoded to a J.

Likewise, if claim was billed with a HIPPS code ending in L, it's being upcoded to an M. If claim was billed with a HIPPS code ending in M, it's being downcoded to a L.

2. Estimate the liability. Use this rule of thumb for a ballpark figure: "For a quick estimate of the dollar impact, an upcode/downcode between J and K would normally be around $200, while an upcode/ downcode between L and M would normally be around $500," Little notes.

3. Get specific. If you'd like to determine your M0175 takebacks more precisely, you can refer to the online pricer software or a listing of payment rates for that period of time and actually look up what the new payment would be, Little suggests.

Example: "If a final claim was billed at HAEJ1 and has been suspended for the M0175 edit, the quick estimate would be that the new claim amount would pay approximately $200 more," Little says. "To be more specific, an agency could look up the payment rate for HAEK1, which is going to be the new HIPPS code, for that particular episode date."

Adjustments Cost One Agency Tens of Thousands

Some of the HHAs served by billing company Astrid Medical Services in Corpus Christi, TX are seeing "some pretty brutal numbers" for takebacks, notes Astrid owner Lynn Olson.

CMS estimates HHAs will have to pay back an average of $4,000 per agency for M0175 mistakes in FY 2001, for a total of $23 million. But the amount of takebacks will vary from agency to agency depending on size and M0175 accuracy in the first year of PPS.

Alacare Home Health and Hospice in Birmingham, AL will owe $42,000 for FY 2001, reports Alacare President John Beard. That includes a $66,000 overpayment and $24,000 underpayment.

Those numbers may seem steep at first glance, but they're actually "a small percentage based on [Alacare's] total dollar volume," Beard explains. The 21-office agency had about $24 million in Medicare revenues in FY 2001, so $42,000 is less than two-tenths of a percent of that figure, he says.

Consider an Appeal

Warmack urges agencies to investigate "at least a representative sample size of the claim," she says. "If the providers find a significant loss with the sample, they should seriously consider investing the effort in reviewing all the claims. Intermediaries have been known to make mistakes too."

HHAs may want to wait and see the net bottom line provided by RHHIs on Nov. 28 or Dec. 9 before taking time-intensive action, Adams notes. "Once an agency knows how much it might need to repay Medicare, then it can decide the value of the additional research per claim to decide what to do next."

NAHC advises HHAs to consider appeals of adjustments. Agencies should "immediately begin gathering evidence to support that they have operated in 'good faith' and are without fault regarding the M0175 inaccuracies," the association says.