Home Health & Hospice Week

Agencies angered by unexpected denials.

Anew Medicare claims edit is drawing more blood than many home health agencies expected. Going into the OASIS matching edit that took effect April 1, many providers thought they were relatively safe from the claims-denying procedure. They knew they were transmitting their OASIS data on time and their data submission software even validated that fact.

Then, the edits hit, and agencies have found out exactly how foolproof their OASIS data submission really is.

It’s too early for the HHH Medicare Administrative Contractors to have specific data on the edit denials, representatives from all three MACs tell Eli. But the MACs have all put out new guidance in the last few weeks emphasizing the edit’s requirements.

“The Home Health and Hospice Provider Contact Center (PCC) continues to receive calls regarding this requirement,” adds MAC CGS in its latest provider education article on the matter.

Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas, says he’s been hearing from agencies angered by their denials due to these edits. “Way too many” claims have been denied under this edit, Olson tells Eli. “Here at AMS we were all surprised at the number of providers/claims that got caught” by the edit, he continues.

Reminder: The edit denies claims when there is no matching OASIS file for the claim, and the final claim is submitted more than 40 days after the OASIS completion date in M0090. It checks these four items against each other in the claims and OASIS databases, CGS reminds agencies:

• HHA Certification Number (M0010)
• Beneficiary Medicare Number (M0063)
• Assessment Completion Date (M0090)
• Reason for Assessment (M0100) equal to 01, 03, or 04.

Each Denial Can Cost HHAs Thousands Of Dollars

The devastating aspect of the edit is that its denials are nearly unappealable (see story, p. 179), the denials strip the entire episode’s reimbursement away, and most agencies get denials when they think they’ve actually submitted the OASIS on time.

The problem: Often, agencies are checking to see that they submitted the OASIS file prior to filing the End of Episode claim, notes reimbursement expert Melinda Gaboury with Healthcare Provder Solutions in Nashville, Tennessee. But they are failing to check whether the OASIS system accepted the OASIS file.

Solution: CMS, the MACs, and reimbursement experts all agree — you must check OASIS Final Validation reports to ensure the OASIS was accepted before you bill the EOE claim (see more denial-fighting tips, this page).

The edit is bringing to light systemic problems that HHAs didn’t know they had. “What we’ve seen in a number of clients are issues that started to surface highlighting practices that really have to change,” notes M. Aaron Little with BKD in Springfield, Missouri. Often changes are needed “regarding the time and processes required to review the OASIS prior to submission to avoid later corrections and resubmissions,” Little says.

Don’t expect much relief from Medicare about the issue. “We have educated providers that OASIS submission has been a longstanding requirement and is a condition of payment for home health episodes of care,” the CGS representative tells Eli.