Home Health & Hospice Week

It may be your finances that need hospitalization after looming takebacks for the OASIS item on prior hospital stays hit.

The Centers for Medicare & Medicaid Services is waiting on the HHS Office of Inspector General to issue M0175 overpayment reports on all four regional home health intermediaries before implementing retroactive takebacks for the OASIS mistakes, a CMS source confirms.

And the OIG has just issued its report on Palmetto GBA, the biggest of the four RHHIs. That leaves the reports on United Government Services and Cahaba GBA left - two down, two to go.

For fiscal year 2001, the first year of the prospective payment system, Palmetto overpaid HHAs $10 million when agencies failed to mark an existing hospital stay within 14 days of home care admission. The OIG bases that estimate on a sample of 199 claims with the mistake, in which it found $57,861 in overpayments, according to its new report (A-04-03-00018).

In examples given, omitting the hospital stay resulted in an extra $173 for a patient not requiring at least 10 therapy visits and an extra $469 for a patient meeting the therapy threshold, the OIG says.

CMS is sticking by its estimate that M0175 recoveries will cost an average of $4,000 per agency, a CMS official tells Eli. But that estimate is based on a draft of an OIG report, and is for FY 2001 only, the source explains.

That means if the mistake rate held true for the three-and-a-half years since PPS began, the estimated takeback per agency would be $14,000. And CMS intends to go back and recoup M0175-related funds for all that time, including making recoveries for two years in 2004 (see Eli's HCW, Vol. XIII, No. 8, p. 58).

Overpayments for the OASIS item shouldn't have a chance to stack up that much again, as pre-payment edits for billing of the item will go into place April 1.

Agencies have no idea how much of an impact the M0175 recoupments will have on them, says Abilene, TX-based consultant Bobby Dusek. That's because there is no way to know how accurately they answered the OASIS item in the past without manually checking every patient.

Try this: To avoid M0175 downcodes and takebacks in the future, Dusek recommends checking the common working file through HIQA both at admission and before submitting the final claim. That will help catch prior institutional stays that don't show up on admission because hospitals, skilled nursing facilities or rehab facilities haven't sent in their claims yet. (See Eli's HCW, Vol. XIII, No. 5, p. 35 for instructions on checking the CWF.)