Home Health & Hospice Week

One intermediary delays the recoupments.

Now that the holidays are over, it's time to get down to business on the imminent M0175 adjustments for the first year of PPS.

The Centers for Medicare & Medicaid Services is moving full steam ahead to recover 2001 overpayments based on the OASIS item on prior inpatient stays. "The M0175 project is still on track and the schedule has not changed," a CMS official tells Eli.

That schedule, set out in Oct. 20, 2006 Trans-mittal 1079, calls for regional home health intermediaries to issue overpayment letters Jan. 18. The intermediaries then will recoup the funds 16 days after the date of the letter (see Eli's HCW, Vol. XV, No. 38).

"We are on track with making the HHA M0175 adjustments and issuing the demand letters," a Palmetto GBA spokesperson says.

The HHS Office of Inspector General estimates $23 million in M0175 overpayments from fiscal year 2001, the first year under the home health prospective payment system. CMS and Palmetto have no updated estimates for the over- and underpayments that will commence in a few weeks, they say.

No letters: Home health agencies that will receive M0175 refunds rather than overpayment demands shouldn't see letters, advises consultant M. Aaron Little with BKD in Springfield, MO. Little expects only agencies with overpayments to receive demand letters.

Hold-up: One intermediary won't be making the M0175 takebacks and refunds by the scheduled date. Cahaba GBA recently transitioned to a new data center, an RHHI official tells Eli. In the process, some claims history files didn't translate properly.

"We might not be able to meet the original timeframes for doing those adjustments because of the history corruption," the Cahaba source says. The intermediary can't perform the work related to the M0175 adjustments until the claims history is corrected.

Cahaba doesn't have an estimated date for when the claims history will be corrected or when it can issue the M0175 demand letters and refunds. The intermediary will keep agencies informed via its Web site and messages to providers, the official says.

What To Do Now

Your opportunity to do any in-depth analysis of M0175-related claims adjustments for 2001 mostly has passed, experts agree. But there are still some vital steps you should take when you receive a M0175 demand letter.

Do this: Check the dates of the hospital stay and the home health admission for any adjusted claims, recommends Abilene, TX-based consultant Bobby Dusek. PPS payment is reduced when a patient has an acute care hospital stay and a skilled nursing facility or rehabilitation facility stay within 14 days of home health admission, Dusek points out. So make sure the episode actually meets those timelines.

Tip: If you have too many adjusted claims to confirm each one, at least confirm a sample of them, Little urges. 

Waste no time: If you decide to appeal, take action immediately to avoid recoupment, Little advises.

If you uncover an incorrect date, you'll need "rock solid documentation" to appeal the adjustment, Little counsels. "The chances of this actually occurring are likely to be very slim," he concedes. Many agencies' computer systems won't even allow them to double-check their own admission dates back to 2001.

The overwhelming majority of the M0175 adjustments will be correct, expects consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. And agencies have such a small window of time to appeal that they are unlikely to dispute takebacks, Gaboury predicts.

Tip of the Iceberg

The demand letters going out this week are for M0175 adjustments in the first year of PPS only. Gaboury expects to see CMS and the intermediaries recoup M0175 payments from the next few years of PPS rather quickly, probably within the year.

HHAs received $48 million due to incorrect M0175 answers in 2002 and 2003, the OIG estimates (see Eli's HCW, Vol. XV, No. 14).

Takebacks diminished: However, agencies' M0175 information-collection practices improved as PPS went on ...quot; especially after the OIG began spotlighting the issue in a series of reports and CMS began running ongoing edits for the item in 2004. So takebacks in subsequent years aren't likely to be as large as in the first years of the payment system.

Note: For tips on honing your M0175 skills, see next week's issue of Eli's Home Care Week.

Did You Know?

M0175 overpayments come about when home health agencies fail to mark all the correct responses to the OASIS item on prior inpatient stays.  If they mark that the patient had a rehab or skilled nursing facility discharge without also marking that the patient had a hospital discharge in the 14-day time period prior to admission, the episode receives an extra point in the service utilization domain.

That extra point bumps the HIPPS code up from a "J" or "L" in the fourth position to a "K" (without therapy) or "M" (with therapy). That results in an extra $200 for a non-therapy patient and an extra $600 for a therapy patient.

Underpayments occur when the reverse happens--agencies mark a hospital stay without a rehab or SNF stay when one occurred.  

Source: HHS Office of Inspector General, http://www.oig.hhs.gov/oas/reports/region1/10300500.pdf