Home Health & Hospice Week

View the recoupments, based on patients' prior inpatient stays, starting Oct. 24.

You may have to tighten your budget belt once you get a look at your pending M0175 adjustments under the first year of the prospective payment system.

The takebacks based on the OASIS item on patients' prior inpatient stays, which the Centers for Medicare & Medicaid Services have threatened for years, are finally going to hit next month. And starting this month, you'll get your chance to minimize the impact as much as possible by checking that the M0175 adjustments are accurate (see story, later in this issue).

How it works: Regional home health intermediaries will run the M0175 downcode and upcode files CMS has furnished. Then they will suspend the adjustment claims created so home health agencies can verify them, CMS says in a new Medlearn Matters article.

"During the five weeks following October 24, HHAs may inspect the adjustments to determine how many apply to their agency and to identify any claims that may have been identified for adjustment in error," the article says. "If a downcoding error is found (that is, an adjustment claim for which the HHA is certain there was no prior inpatient stay), HHAs may contact their RHHI to request that the error be corrected."

The RHHIs then will process the adjustments the week of Nov. 28, the article confirms.

CMS is waiting to see how the fiscal year 2001 adjustments go before scheduling the adjustments for any subsequent years, a CMS official tells Eli.

OIG Puts M0175 Bill at $23 Million for 1st Year

CMS expects the adjustments' cash impact on agencies to be insubstantial, it says in the Medlearn article. But the HHS Office of Inspector General has estimated that the four RHHIs paid out $23 million due to incorrect M0175 responses in the first year of PPS (see Eli's HCW, Vol. XIII, No. 13).

The OIG, however, didn't figure M0175 underpayments into its calculations. After intense pressure from the home care industry, CMS agrees to adjust for underpayments as well as overpayments for the first three years of PPS.

Consultant M. Aaron Little with BKD in Springfield, MO expects to see overpayments outstrip underpayments when the adjustments commence. CMS' estimate of the overpayments only is $4,000 per HHA.

Individual agencies' takeback amounts will depend on how accurately they were able to answer M0175, notes consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

Watch out: HHAs that received many referrals from rehab hospitals or SNFs will be most likely to encounter higher recoupment rates, since they were more at risk of marking a rehab or SNF stay without knowing about the earlier acute hospital stay, expects Abilene, TX-based consultant Bobby Dusek.

Tally Your M0175 Tab

Agencies finally will be able to calculate their M0175 liability for FY 2001 when the RHHIs put the suspended adjustments up for viewing, Little notes. They can just review the claims and add up the adjustments.

Warning sign: If you saw a lot of claims downcoded when the prepayment M0175 edit took effect in April 2004, that means your information on prior inpatient stays is more likely to have been inaccurate all along. As a result, you'll probably see a bigger bill for these retroactive recoupments, Gaboury cautions. 

Note: The Medlearn Matters article is online at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0561.pdf.