Home Health & Hospice Week

Can you estimate your M0175 liability for the coming retroactive recoupments?

Tens of millions in M0175 takebacks are coming down the pike, and most home health agencies have no idea how much they stand to lose.

That liability could be significant, with a total of $23 million in overpayments assessed for the first year of the prospective payment system alone.

In its last report of the M0175 series, the HHS Office of Inspector General estimates that agencies served by regional home health intermediary Cahaba GBA owe $5.6 million for fiscal year 2001 overpayments based on M0175. That figure is extrapolated from the $55,600 in overpayments the OIG found by auditing 200 claims that failed to identify a prior hospital stay within 14 days of home health admission.

Most of those mistakes were preventable, the OIG claims in the report. "In 28 of the 30 claims reviewed, the beneficiary's medical file maintained by the HHA indicated that an inpatient hospital discharge occurred within the 14 days preceding the HHA episode," the report says.

HHAs generally identified only the most recent inpatient stay or counted the 14-day time period incorrectly, the OIG concludes.

Medicare will begin recouping the M0175 overpayments some time after June 1, the Centers for Medicare & Medicaid Services said in its March Open Door Forum for home health.

M0175 Estimates Hard to Come By

HHAs wondering how big a bite Medicare will take out of their payments this summer are in a quandary. "I don't know how to estimate M0175 liability," says Mary Gadd, owner and administrator of Hixon, TN-based Guardian Home Care Inc., which serves 26 counties in Tennessee and Georgia.

"A provider would have no way of knowing," agrees consultant Rick Ingber with ZA Consulting.

But there are a few ways to make educated guesses. A "real general rule of thumb" is $10,000 in recoupments per $1 million in Medicare revenues, suggests consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. But Boyd warns his estimate is based on a small data base and very "raw" data.

Try this: HHAs with cooperative local hospitals may have some luck estimating their coming takebacks, advises Dana Strong with Scarborough, ME-based Strong Consulting.

They can choose a random and statistically valid sample of claims for a fiscal year, then check those against hospital records to see if the patient had a hospital stay within the relevant time period and whether M0175 was checked appropriately, Strong counsels. The agency then can calculate the error rate for the sample and project it to the years' claims.

HHAs can also check for intervening skilled nursing facility and rehab stays to see if those were missed, costing the agency significant funds.

It is most likely only hospital-based or -affiliated HHAs that will have luck with this approach, due to the access to patient hospital records, Strong suspects. v 

Editor's Note: The OIG report is at www.oig.hhs.gov/oas/reports/region7/70304021.htm.