OASIS:
HHAs To See M0175 Underpayments Returned - At First
Published on Sat Aug 07, 2004
CMS relents on assessing only overpayments for OASIS item on prior inpatient stays. How confident are you in your current M0175 information-gathering practices? A recent victory by the home care industry won't keep you from losing up to $600 per affected patient if they aren't up to snuff.
Much to home health agencies' delight, the Centers for Medicare & Medicaid Services has agreed to identify mistakes stemming from the OASIS item on prior hospital, skilled nursing facility and rehab stays that work both for and against providers. "Medicare will ... identify both overpayments and underpayments that resulted from inaccurate reporting of prior inpatient discharges for Federal fiscal years 2001, 2002 and 2003," CMS says in July 30 Transmittal No. 95.
The move has industry experts cheering. "I'm really glad that CMS is doing this," says Bob Wardwell with the Visiting Nurse Associations of America. "It seems only fair," says Wardwell, a former CMS top official who has lobbied for the change.
"This is a very positive result," concurs William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. "It means that a lawsuit is unnecessary." NAHC had been preparing a lawsuit if CMS didn't relent on identifying underpayments due to unreported SNF and rehab stays, in addition to the overpayments resulting from unreported hospital stays (see Eli's HCW, Vol. XIII, No. 10, p. 74).
HHAs can lose nearly $200 on non-therapy patients and $600 on therapy patients when they fail to report a SNF or rehab stay only within 14 days of discharge. Conversely, if they report only the SNF or rehab stay without an existing hospital stay, they owe Medicare the same amount.
What to expect: The impact of CMS' decision to play fair with prior inpatient data will vary from agency to agency. The more unreported rehab and SNF stays, the more money the HHA will see returned or used to offset unreported hospital stays.
Experts are split on whether underpayments will equal overpayments. It's likely there will be "close to as many errors that resulted in underpayments" as overpayments, predicts reimbursement consultant M. Aaron Little with BKD in Springfield, IL. "Many times it's easier to identify whether a patient was in the hospital than it is to identify whether the patient was in a SNF/rehab," Little tells Eli, so unreported SNF and rehab stays are more likely.
Identification of SNF and rehab stays is especially tricky in rural areas, where swing bed hospitals don't require a patient to move beds or rooms to switch from hospital status to SNF or rehab status, Little explains. "If over the last three years clinicians primarily relied on scoring M0175 based on interviews with patients or inpatient [...]
