Medicare Compliance & Reimbursement

Millions of dollars in takebacks based on patient hospital stays are on agencies' horizons.  Despite the fact that the HHS Office of Inspector General hasn't even concluded its series of reports on M0175 inaccuracies, new claims edits based on the issue are poised to recoup millions of dollars from home health agencies. The Centers for Medicare & Medicaid Services has instructed intermediaries to put in place new pre- and post-payment edits that will check whether HHAs correctly identify an inpatient hospital stay in the 14 days before home health admission, according to an Oct. 24 instruction from the agency (Transmittal No. 13). OIG reports on the issue indicate "the Medicare program is vulnerable to make excess payments on HH PPS claims when certain OASIS assessment information is reported in error," CMS says in the transmittal. Specifically, when agencies fail to report a hospital stay while at the same time reporting a skilled nursing facility or rehabilitation facility stay in M0175, it can bump the episode's health insurance prospective payment system (HIPPS) code up to a higher-paying "K" or "M" in the fourth position - a difference of about $200 and $600 per episode, respectively. If agencies record the SNF or rehab stay and the hospital stay, they don't see the increase. While HHAs have a heck of a time obtaining information on prior hospitalizations, CMS and the intermediaries have the information at their disposal. Thus, three new types of edits will take effect for HHAs April 1: Pre-payment RAPs. When requests for anticipated payment come in with a "K" or "M" in the HIPPS code, the claims payment system automatically will check the patient's claims history for an inpatient hospital stay within 14 days of admission to home care. If it finds one, the system will return the RAP to the provider, so the agency can correct and resubmit it. Pre-payment final claims. When a final claim comes in with a "K" or "M" in the HIPPS code, the system again will check it against the patient's claims history for an inpatient stay. If one has shown up since the RAP check, the system automatically will adjust the claim to the lower-paying HIPPS code using an "L" or "J," respectively. Post-payment claims. Because hospitals have up to 27 months to submit and be paid for their claims, CMS annually will analyze its National Claims History file to ferret out claims that were paid at the higher, no-hospital stay rate, but whose patients eventually did end up with a hospital stay recorded during the 14-day time period. The intermediaries then will recoup the money for those claims retroactively. An official with regional home health intermediary United Government Services expects most overpayments [...]