OASIS Alert

Hint: Submit OASIS data first.

CMS has had plans to roll out edits designed to check whether your claims match up with your OASIS data for some time. A recent OIG report may just push that issue higher up on the agenda.

In October 2012, the Centers for Medicare & Medicaid Services implemented edits crosschecking inpatient rehab facility claims against their submitted assessment data. CMS planned to implement similar edits for home health agencies, cross-checking HIPPS codes on claims against accepted OASIS data, in April 2014, according to a new report from the HHS Office of Inspector General.

CMS hasn’t followed through on the plan yet, which appears to be fortunate for HHAs. Of the 100 claims that the OIG sampled from 2010, the majority didn’t pass muster. The intermediary made payments totaling $157,000 for 65 claims “that should not have been paid because the HHAs had not submitted accepted OASIS data,” the watchdog agency says in a new report.

The OIG estimates that “the RHHI made $25.1 million in Medicare overpayments because it did not deny claims that HHAs had submitted without the required OASIS data, which is a condition of payment,” the report says.

The OIG urges CMS to “consider reopening the … 3,819 claims [that] were paid before OASIS data were accepted and 12,663 [that] did not match to OASIS data … and recover any overpayments.”

Should You Expect OASIS-Related Takebacks Ahead?

In its response to the report, CMS agrees to “conduct an analysis based on contractor resources to determine an appropriate number of claims to review. CMS will instruct the contractor to review the claims and take appropriate action.”

The OIG also wants CMS to “encourage RHHIs to conduct periodic post-payment reviews of HHA claims, which would include ensuring OASIS data supports claims, until sufficient prepayment controls are established.”

Fortunately, CMS pushes back on this advice. CMS does not concur with this recommendation. “MACs are already reviewing HHA claims on a prepayment basis at this time,” CMS points out in its response. “Furthermore, enhancements are being made to the Medicare Contractors Extract Systems, such as adding more data fields to increase the probability of locating the OASIS.”

Watch out: “The OIG is taking a hardline approach in these audits and a similar approach would be expected of Medicare contractors, particularly RACs and ZPICs,” warns the National Association for Home Care & Hospice. “The OIG rarely gives up in these types of matters and the Medicare contractors often pursue any possible overpayments.”

Do this: HHAs should “evaluate their claim submission systems to ensure that claims are not prematurely submitted prior to the OASIS acceptance,” NAHC advises in its member newsletter.

This is an item agencies may be overlooking in their prebilling audits, since it doesn’t often affect claims payment, cautions billing expert M. Aaron Little with BKD in Springfield, Mo.

“While I was bit surprised that agencies got paid for 65 percent of audited claims that were submitted with erroneous data or no OASIS data at all, I’m not surprised that agencies stumbled in the submission process,” says Beth Johnson, MBA, BSN, RN, CRRN, HCS-O, HCS-D with Johnson, Richards, & Associates in Brighton, Mich. “We’ve worked with numerous agencies that have needed to put into place more robust processes to track OASIS submission.”

Check Your Processes for Vulnerabilities

Lax OASIS submission habits can stem from a variety of problems. Is your agency at risk? Beware of these common risk areas.

Staff turnover: Sometimes an agency may inadvertently go for a period without submitting its OASIS due to turnover, Little points out. “Someone forgets to tell the newbie that it’s a function that’s part of their new job responsibilities.”

Poor tracking: “If you’re not tracking your OASIS documents, you’re not tracking your revenue,” Johnson says. Agencies often do a great job with timely submission of starts and payments on RAPs, but have huge amounts of money tied up in accounts receivable because they’re not completing the loop when it comes to OASIS documents that close episodes and allow for final billing, she says.

Overwhelmed: Some agencies are behind on everything, Johnson says. “I think some of this speaks to the inherent difficulties in managing home care versus hospital staffs: home care employees are road warriors, rarely in an office.” Home health agencies require different team-building and leadership styles than in a more traditional brick-and-mortar health care setting, she says.

Missing the signs: Your software likely has features that will help you to make sure your agency submits OASIS data appropriately. But if you aren’t familiar with tracking features and reporting capability, you could still be letting things slip through the cracks. “Electronic medical records systems are almost essential in preventing submission of inaccurate claims on the front end, since most software programs already contain opt-in quality control algorithms that point out discrepancies between HIPPS codes and M-item responses,” Johnson says.

Note: The report is at http://oig.hhs.gov/oas/reports/region1/11200508.pdf.