Home Health & Hospice Week

Major money will be on the line when new edit hits April 1.

If you think the upcoming edit requiring an OASIS assessment for every final claim you bill won’t impact you much, you may need to think again.

Home health agencies should be on top of the OASIS requirement already, points out Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. The Request for Anticipated Payment and final claim require both the HIPPS code and OASIS Matching Key derived from the OASIS assessment.

“I have been stressing OASIS timeliness since implementation of OASIS-C1, back in January 2015,” notes Rose Kimball, owner of billing company Med-Care Administrative Services in Dallas. When OASIS submission switched over from state databases to the federal ASAP system, “I taught, if OASIS was not in the database when final bill was submitted, [the] claim could be denied,” Kimball tells Eli.

That’s exactly what HHAs have seen in medical review, notes billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn. While the automated denial edit for the OASIS is not in effect until April, claims reviewed via Additional Development Requests have been receiving denials for lacking OASIS already.

But despite those reasons to be prepared, “like with any new claim edit, I think this one might catch some agencies by surprise by its potential impact,” predicts M. Aaron Little with BKD in Springfield, Mo.

And that impact could possibly be a whopper, Gaboury warns. If one batch of OASIS assessments doesn’t get transmitted and the final claims for those episodes do, all of those claims get denied. If a week or two of non-transmitted OASIS assessments results in erroneously submitted claims, “there’s going to be $200,000, $300,000, $400,000, $500,000 before they even know what’s happening,” Gaboury stresses.

And denials will have basically no chance of appeal, Kimball notes. The OASIS time frame and requirement for the matching OASIS file “are in the regulations,” she points out.

Watch out: It’s “a scary thing that claims can be denied without medical review and such claims — for the most part — cannot be appealed,” Little says. “That’s something very new to the home health industry.”

Beware This Nightmare Scenario

Agencies most at risk of punishing denial amounts are those that think they are most protected from the edit, Gaboury warns — those who have billing software that supposedly alerts them when a matching OASIS file has been transmitted or not.

Pitfall: But watch out for what those messages really mean, Gaboury exhorts. In many billing software programs, a staffer exports the OASIS file to the agency computer hard drive, then that staffer submits an OASIS file to the ASAP system. When the OASIS data is exported, the billing system marks the related claims as ready to go, Gaboury explains.

Scenario: But what can happen instead is that the staff person exports the OASIS file to the hard drive, then gets interrupted. “Maybe she gets a call from her kid’s school at 3 p.m. on a Friday and her son has a broken arm,” Gaboury offers. When she returns to work on Monday, she has forgotten she didn’t take the final step to transmit OASIS to ASAP, and the billing software has marked all those final claims as OK to send.

“Maybe there are 100 Starts of Care in that file,” Gaboury says. If you rely on your billing software only, you won’t find out those SoCs didn’t get transmitted until you start receiving the denials. And by that time you could be socked with major denial amounts that are unappealable.

That’s just one example of how agencies can get walloped by this new edit. Other potentially reimbursement-draining scenarios include:

• Staff turnover. “Often, we have seen turnover contribute to processes being significantly disrupted,” Little relates. “One such process is the submission of the OASIS data, where during the turnover and personnel replacement and retraining period it’s discovered that OASIS data was not submitted for a period of time.” Under the new OASIS matching edit, turnover could result in “a period of time when claims begin to be denied, particularly those claims that are for episodes that do not last the full 60 days.”
• Software conversion. As anyone who has been through them knows, software conversions can really throw your processes for a loop. “Any time there is a conversion in an EMR, it causes all kinds of process disruptions,” Little says. That includes OASIS submission.
• Failing to confirm acceptance. Even if you have a process for making sure the OASIS is actually submitted, it won’t mean anything if you fail to check that the ASAP system accepts the files.
• Vendor problems. It may take a load off your shoulders to have an outside vendor submit your OASIS data for you, but that doesn’t let you off the hook for compliance. If your vendor has a disruption in service, you are still the one who bears the responsibility for the impact — including denials resulting from this edit.

Note: See the Medicare transmittal CR 9585 explaining the edit at www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/Downloads/R3629CP.pdf.