Home Health & Hospice Week

A little claims investigation can go a long way.

You can minimize the coming M0175 mayhem with some detective work of your own.

Home health agencies shouldn't assume every M0175 adjustment thrown at them is correct, especially when the adjustments can cost up to $600 per claim. Later this month regional home health intermediaries will display the adjustments based on the OASIS item for patients' prior inpatient stays for fiscal year 2001. That's your five-week window to refute any erroneous adjustments.

Follow this expert advice to make sure you keep your rightful reimbursement:

1. Check out the adjustments. As soon as the RHHIs give instructions on how to view the suspended adjustments, you should take a look at your claims, advises consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN. You can add up the overpayments and underpayments to arrive at your M0175 liability.

Both Gaboury and consultant M. Aaron Little with BKD in Springfield, MO encourage HHAs to verify the accuracy of every adjustment.

But agencies with too much on their plates already can use a quick cost-benefit analysis to see if investigating the M0175 adjustments is worth their time, suggests Abilene, TX-based reimbursement consultant Bobby Dusek. If there are just a handful of claims suspended with a relatively low dollar amount involved, HHAs may want to skip any in-depth investigation, Dusek offers.

2. Verify adjustment accuracy. "Each agency needs to verify that each adjustment is correct," Gaboury urges agencies.

You first can check the prior stay information against the Common Working File. When using the CWF, use the "APP Date" field on the HIQA/ELGA CWF inquiry screen, Little counsels. "This option allows providers to view hospital and SNF inpatient stay information from past periods," he tells Eli

But don't make the mistake of assuming the CWF is always right. "Because the CWF data is based on provider claims data, there is certainly the possibility for errors," Little notes. If you have conflicting information, you can follow up with your own detective work including speaking to the institution that billed the prior stay.

3. Request corrections. Agencies should report errors and request corrections to the M0175 adjustments from their RHHI, the Centers for Medicare & Medicaid Services instructs in a Medlearn Matters article issued Sept. 28. Intermediaries haven't yet issued the procedures for reporting errors, Dusek notes.

Pointing out a discrepancy between the adjustment and the CWF should be a fairly simple procedure, experts predict. But reporting an error and requesting a correction for a prior stay that conflicts with the CWF may be more of a challenge. "The agency should be able to present documentation to support that the CWF is incorrect," Gaboury says. "That is going to be difficult if an inpatient stay is reflected in the CWF."

In such cases, agencies should provide available documentation to support the request, Little suggests. That may include items such as phone notes from a SNF, rehab or hospital discharge coordinator, for example.

4. Request help. "HHAs that believe the processing of all adjustments at one time will cause a hardship may also contact the RHHI to request special consideration," CMS says in the article.

When agencies review their suspended claims for the financial impact, they should gauge whether the takebacks will cause financial hardship, Little advises. If so, he suggests contacting the intermediary to propose a recoupment plan conducted in phases rather than all at once.

Different intermediaries are likely to have different criteria and procedures for special consideration, Gaboury expects.