Home Health & Hospice Week

CMS mulls adding positive corrections for prior SNF and rehab stays. 

Takebacks for incorrect M0175 answers will begin sooner than you think, but may also be less than expected.

Regional home health intermediaries are waiting on the HHS Office of Inspector General reports on the issue before taking action, the Centers for Medicare & Medicaid Services said in a Nov. 5 Open Door Forum for home health.

The OIG already has issued its report regarding M0175 overpayments for home health agencies served by RHHI Associated Hospital Service of Maine (see Eli's HCW, Vol. XII, No. 27, p. 210). AHS agencies will see an estimated $1.9 million recouped for fiscal year 2001 overpayments related to M0175, according to the report.

Reports for the other three RHHIs - Palmetto GBA, Cahaba GBA and United Government Services - are expected to follow shortly, a CMS official tells Eli. Once the intermediaries receive the reports, they will work quickly to institute the takebacks. The first round of recoupments will encompass fiscal year 2001 spanning from Oct. 1, 2000 (when the prospective payment system began) to Sept. 30, 2001, the CMS source explains.

HHAs served by AHS are likely to receive notification about their recoupments by the end of this month, the CMS official adds - not next April when the pre-payment edits begin (see Eli's HCW, Vol. XII, No. 39, p. 306). The takebacks are expected to occur all at once, unlike partial episode payment (PEP) recoupments that are processing gradually over a two-year period, with some unforeseen exceptions (see Eli's HCW, Vol. XII, No. 39, p. 309).

M0175 recoupments are estimated to be only about one-tenth the amount of PEP recoupments, experts say. But that still will mean millions in takebacks just for FY 2001 alone.

Agencies do appear to be getting a break on the time between FY 2001 and the present. RHHIs likely will begin the annual post-payment audits of M0175-related billing in mid 2004, the CMS source indicates. And those audits will go back only one year. Thus, claims from FY 2002 and most of FY 2003 likely will escape the takebacks.

Rehab & SNF Stays Also Hard to ID 

Another factor that could mitigate the recoupments is CMS' willingness to make M0175 corrections in providers' favor as well as against them. The agency's Oct. 24 instructions to intermediaries in Trans. No. 13 tells them only to make corrections when a hospital stay within 14 days of admission or resumption of care was missed in M0175, and thus a higher amount was billed, confirms a Palmetto official.

But in the Open Door Forum, Administrator Tom Scully said CMS will try to make corrections when agencies fail to mark skilled nursing facility or rehabilitation facility stays in the same time period in M0175. When patients have a SNF or rehab facility stay and do NOT have a hospital stay, the payment rate is bumped up about $200

for a patient who doesn't meet the 10-visit therapy threshold and about $600 for a patient who does require therapy, the OIG notes in its report.

Scully's pledge came after an HHA called into the forum and said an internal audit uncovered that just one branch of the large agency had lost $20,000 due to the inability to identify SNF and rehab stays. It's "very difficult" to determine licensing status of some hospital beds, especially swing beds, the caller said. With swing beds, the patient stays in the same hospital bed but can be moved from the acute hospital to SNF or rehab payment category.

Scully's announcement also came after Bob Wardwell of the Visiting Nurse Associations of America urged CMS to be fair in its payment practices and "pay the claims correctly" whether it increases or decreases HHA reimbursement.

CMS hadn't considered including corrections resulting in higher HHA payments "because we're assuming you're catching all the positive stuff," Scully quipped. Officials reasoned SNF and rehab stays would be easier to identify because they would be likely to occur immediately before the home health admission, while a hospital stay might take place before an intervening SNF or rehab stay and thus be harder to catch. SNF and rehab discharge information "is a lot more available to the HHAs," one staffer said in the forum.

The deal is far from sealed. Scully said CMS would "try" to do it and a CMS official tells Eli the agency will "look into doing it."

Many in the home health industry are highly skeptical that the change that would increase HHA reimbursement will take place. "I'll believe it when hell freezes over," one industry veteran says.

But Wardwell says there's a fighting chance the change could take place.

"The CMS staff given this responsibility will genuinely try to do so," he believes. But considering CMS' resource limitations, "the home health community will need to keep the issue alive ... to make it happen," he tells Eli.

There's a Reason for M0175 - But Is It a Good One? 

CMS officials assured forum listeners there is solid logic behind lowering payments when the patient's had a recent hospital stay. While it "sounds odd," the idea is that patients who have a hospitalization prior to the 14-day period to qualify for the SNF "are fairly long-stay SNF patients who are higher cost" than those with shorter stays, a staffer explained.

When constructing PPS to begin with, correct prior stay information culled from claims data was used rather than possibly erroneous data reported by agencies, CMS explained in response to one industry rep's question. Thus, the extra payments for wrong information weren't built into the system from the get-go, which was a potential argument against the recoupments.

CMS reminded agencies at the forum that while it will be making millions in recoupments, "there is not an allegation of wrongdoing" on HHAs' part.

Editor's Note: CMS instructions to implement M0175 edits and recoupments are at www.ms.gov/manuals/pm_trans/R13CP.pdf. The OIG's report on AHS overpayments is at http://oig.hhs.gov/oas/reports/region1/10300500.pdf.