Home Health & Hospice Week

United Government Services overpaid HHAs $5.3 million -- and it plans to get it back. 

Three down, one to go -- the countdown to M0175 recoupments just got shorter.

That's thanks to the HHS Office of Inspector General's issuance of a report assessing regional home health intermediary United Government Services' fiscal year 2001 overpayments for the OASIS item on prior hospital stays.

Once the OIG has issued reports on all four RHHIs, the Centers for Medicare & Medicaid Services will initiate recovery of the identified overpayments for the first year of the prospective payment system. Reports on UGS, Palmetto GBA and Associated Hospital Service of Maine are out, and just the report on Cahaba GBA remains unreleased.

The problem: The OIG estimates UGS paid home health agencies $5.3 million when it shouldn't have, based on the agencies' answers to OASIS item M0175. When HHAs failed to indicate a hospital stay in addition to a skilled nursing or rehab facility stay within 14 days of home health admission, they overbilled Medicare.

In two examples the OIG gives, agencies received an extra $190.15 for a claim that was downcoded from a "K" to "J" service utilization level, and $549.87 for a claim downcoded from an "M" to "L" level.

In a sample of 200 claims for patients with prior hospitalizations within 14 days, the OIG found $55,762 in overpayments. Extrapolated to the FY 2001 universe of claims with hospitalizations, the overpayment reached $5.3 million. That compares to a $10 million overpayment at Palmetto (see Eli's HCW, Vol. XIII, No. 10) and $2 million at AHS (see Eli's HCW, Vol. XII, No. 27).

CMS originally estimated the national overpayment for FY 2001 to be $25 million. To reach that mark, overpayments at Cahaba will have to be more than $7 million.

This OIG report places more blame on HHAs for the billing mistake than previous reports have. For example, in the Palmetto report, the OIG admits that hospitalization information often wasn't available from the SNF or rehab facility when the patient transferred to home health.

But the UGS report insists "prior inpatient hospital stay information was available to the HHAs in most cases." OIG investigators visited five agencies in California, and three of them "responded that it was possible to determine a hospital discharge prior to the skilled nursing or rehabilitation facility stay by reviewing the physician referral and medical records available to them," the report adds.

And OIG investigators found SNFs and rehab facilities helpful. Six facilities contacted told investigators "information referred to the HHAs often included the hospital stay, or if not, it could be provided if requested."

CMS now maintains that agencies should be able to identify hospitalizations through the common working file, notes Bob Wardwell with the Visiting Nurse Associations of America.

Advice to check the CWF "is well-intended but not terribly helpful," Wardwell maintains. "CMS offers an inefficient and labor-intensive process to run down information HHAs need to bill accurately," just when the General Accounting Office has blasted agencies with high overhead costs as weak and inefficient (see Eli's HCW, Vol. XIII, No. 9).

Editor's Note: The OIG report is at http://oig.hhs.gov/oas/reports/region9/90300042.pdf.