Home Health & Hospice Week

Appeals questions stave off recoveries related to patients' prior inpatient stays

Home health agencies will be able to hang onto millions of dollars at least a bit longer. The Centers for Medicare & Medicaid Services has called a halt to M0175 recoveries slated to begin Nov. 28.

The takebacks are caused by incorrect answers to the OASIS item on prior inpatient stays during the first year of the prospective payment system, fiscal year 2001. "The recoveries are currently on hold while CMS reviews whether our recovery process is fully compliant with the requirements of [the Medicare Modernization Act] section 935," a CMS official tells Eli.

MMA 935 requires CMS to delay recovery of overpayments until the second level of Medicare appeals, which is now the Qualified Independent Con-tractor (QIC) level, notes William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. NAHC sent a letter to CMS in November raising the MMA 935 issue along with a host of other problems related to the recoveries.

Originally, CMS expected regional home health intermediaries to make the M0175 recoupments from current claims payments without waiting for the required appeals time. Now CMS and the RHHIs say they are in intense discussions about how to comply with requirements.

"We are trying to nail down all the details on how to administratively pull this off," says a source from RHHI Cahaba GBA.

The intermediaries are awaiting a decision and instructions from CMS, adds an official with RHHI United Government Services.

Simple Question Leads To Many Complications

The MMA 935 issue is the problem that "stopped CMS in its tracks" on the M0175 adjustments, Dombi notes. But NAHC has identified a host of other problems with the recoveries, including that they may not meet notice and opportunity for rebuttal provisions in Medicare regulations.

The information RHHIs have posted doesn't clearly tell agencies how much money they owe, Dombi contends (see Eli's HCW, Vol. XIV, No. 40). That could mean the postings aren't official notices as required.

The deceptively simple question in M0175 has proven very complicated to answer in practice, Dombi points out. "Patients don't know where they were and facilities don't know what they are," he laments.

Example: Hospitals in Maryland don't operate under the Medicare PPS system and thus aren't certified as rehab hospitals. So when a patient was discharged to the rehab part of a Maryland hospital, it shows up as a regular hospital for M0175 purposes.
 "It is a nutty element of PPS," Dombi says of the OASIS question. He hopes CMS will give up on making retroactive recoveries for M0175 and focus on fixing the many problems surrounding the question in the future. The cost of pursuing appeals both on providers' and CMS' part is likely higher than the recoveries to be made, Dombi estimates.

Resumption Date For Recoveries Hazy

CMS has no revised timetable for the M0175 adjustments, the agency official tells Eli.

"A lot is up in the air at this point," Dombi says.

But one RHHI source says he expects the recoveries to resume "in the near future," probably in the next few weeks. In a Nov. 30 bulletin to providers,RHHI Associated Hospital Service says new M0175 instructions "will be issued shortly."

Industry observers expect the process may take longer than a few weeks, however.

The intermediaries say they will notify providers as soon as they have a new due date for the adjustments.