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So recently, we have received a ton of emails, phone calls and other signals of distress from clients and others because they are receiving letters from their Recovery Audit Contractor stating that a potential overpayment has been identified via a semi-automatic review.  If the agency agrees with the denial, there is nothing to worry about.  The FI will get in touch with them and arrange for repayment.  If they dispute the information, the agency has 45 days to appeal to their recovery audit contractor. 

I would not have a problem with this except the letters I have seen are threatening to assess and overpayment based upon rules that are not in existence to the best of my knowledge.

Depending on where you live, your letter may be questioning homebound status or OASIS data submission.  In the South, most letters are from Connolly Healthcare regarding OASIS data.

These letters identify an agency’s failure to comply with the Conditions of Participation and earmark the offending claim for denial.  If you get one of these letters, bear in mind the following when writing your appeal:

On January 1, 2010, it became a condition for payment to submit OASIS data prior to billing.  42 CFR 484.210(e) currently reads:

(e) OASIS assessment data and other data that account for the relative resource utilization for different HHA Medicare patient case-mix. An HHA must submit to CMS the OASIS data described at § 484.55(b)(1) and (d)(1) in order for CMS to administer the payment rate methodologies described in §§ 484.215, 484.230 and 484.235.

If you look at § 484.55(b)(1) and (d)(1)  the data described is the comprehensive assessment done at admission and recertification. 

Note that § 484.55(d)(2) is not included in the data required to be submitted.  This refers to the Resumption of Care assessment that does not predicate payment.  For those agencies who are being tentatively denied due to lack of transmission of an ROC.

(Normal people:  what the above says is that you gotta submit the admit or recert oasis prior to billing.)

The payment provision is silent on late assessments.  I strongly encourage you to do everything timely but CMS has forbidden us to discharge and readmit when a recertification assessment is performed late.  CMS offers guidance to agencies in the OASIS Q & A most recently updated in 2009 and current as of January this year with no further reference that I have been able to find.

When an agency does not complete a recertification assessment within the required 5 day window at the end of the certification period, the agency should not discharge and readmit the patient. Rather, the agency should send a clinician to perform the recertification assessment as soon as the oversight is identified. The date assessment completed (M0090) should be reported as the actual date the assessment is completed, with documentation in the clinical record of the circumstances surrounding the late completion. A warning message will result from the non-compliant assessment date, but this will not prevent assessment transmission. No time frame has been set after which it would be too late to complete this late assessment, but the agency is encouraged to make a correction or complete a missed assessment as soon as possible after the oversight is identified. Obviously, this situation should be avoided, as it does demonstrate non-compliance with the comprehensive assessment update standard (of the Conditions of Participation). For the Medicare PPS patient, payment implications may arise from this missed assessment. Any payment implications must be discussed with the agency’s Medicare Administrative Coordinator (MAC).

Because the payment is made by the agencies Medicare Administrator Coordinator (Fiscal Intermediary), it can be assumed that the lack of ADRs from the FI and the fact that the data was submitted timely indicated that no payment ramifications resulted from late assessments.

I know this is all very boring legal mumbo jumbo and I don’t like it any more than you do but thousands of these letters have gone out to agencies.  I have approached Connolly Healthcare, the Recovery Audit Contractor sending out the erroneous edits for OASIS data and they replied with gratitude that I reached out to them and kindly sent me a link to the appeals process.  They were unable to discuss the issues further out of concern for confidentiality.  Note that it has been reported to me that one agency received letters regarding claims for patients at another agency.  Only when I ask questions does their concern for confidentiality appear.

I am not the only one who has reached out to the RACs about what appears to be a faulty program generating semi-automatic reviews tentatively denying agencies based upon rules that do not exist.  I will let others speak for themselves but do not assume that associations created to which you pay membership fees are ignoring this. Call your association if you are a member and ensure that they approach the RACs on your behalf if they have not already done so.

For what it is worth, I know how to write an appeal.  My concern lies in the cost of doing so.  When I write appeals for a client, I bill for it and it is easy to see the cost on my invoice.  When agencies research and write appeals, it costs at least as much but the cost are very difficult to measure.

I am glad I didn’t send the folks at Connolly a Christmas card.  I hate being rude but they are causing a lot of stress and expense to agencies based on bad information.  The respond instructions that you can take valuable time away from your day to address their errors and here’s the part that really threatens to put me in a bad mood:


Please comment or email me if you have received one of these letters. 

6 Comments Post a comment

  1. The same language regarding late reassessments and the updated info on late reassessments are still current in the annual update that was issued yesterday. The references to late reassessments in the Q and A this year have been added to the category questions dated 12/12. What I have seen is that if the OASIS has not been transmitted within 30 days of M0090, they will issue a denial. And as always the OASIS must have been transmitted prior to the final bill on the episode. Remember that one of the criteria for submitting a RAP is that the OASIS has to be ready to transmit.

    December 21, 2012

    • Lisa, as always, you are correct. And I was not clear that some of the denials are for patients prior to 12.1.2010 when the condition was migrated from a condition of participation to a condition for payment. Obviously, we would be idiots if we told our clients not to worry about the conditions of participation but claims are not denied every time a supervisory visit is missed or a med profile sadly doesn’t correspond to the meds at home as noted on survey. Those are conditions of participation as well. Every other instance of failure to meet a CoP is met with an opportunity to put a plan of corrections in place.

      I have not seen any related to the transmission of OASIS data within 30 days of M0090 but it doesn’t surprise me. One had a resumption that was done but not logged but was sent timely. One had a recertification performed late by a couple of days outside the provider’s fault but was transmitted prior to billing the final claim OR dropping the RAP and the claim was from 2009. I have six where the OASIS was not in the state repository prior to billing but the claims were from 2008 and 2009.

      In Louisiana, we have a good OASIS coordinator (or we did until she retired) and if greater than ten percent of any assessments were late, the agency had a formal deficiency sent to them. According to the Feb. OIG report, many states did not have any oversight. There is no distinction between degrees of late transmission. So, if you have an agency with a nurse who has two admits and she doesn’t turn them in and then gets in a wreck or suffers a death in the family, they are going to be late. The RAP cannot be billed because there is nothing with which to calculate the HIPPS. When the paperwork arrives at the office, I tell the agency to carefully consider what addressing the tardy paperwork will entail and plan according to that. If it is late, don’t meticulously deal with it causing all current assessments to be late. Having 20 assessments 1 day is worse than 2 assessments 10 days late. The care of the patients with the late paperwork has already been compromised. If pts are just coming out of the hospital, even one day can be an issue.

      The RAC semi-automatic reviews have hit like a ton of bricks in just the last few weeks. Have you seen any resolved? I can send you the link for information on how to file an appeal if you like. JUST KIDDING.

      It is nothing if not frustrating. What really gets under my skin is that when people talk about ‘health care dollars’, these dollars are included. Thanks for the update regarding the Q & A. I was looking for information relating to a certain time frame before that and when I got it, I quit. I should have been more thorough in my blogging and went searching again:)

      Do share with us any other denials. Now, I know why there is such an uproar about semi-automatic weapons.

      Did Kingsley have an opinion?

      December 21, 2012

      • If we could just get professionals to document their assessments and the skilled care they provided, then the processes, such as transmitting the OASIS, submitting the RAP, providing quality care, etc would run so smoothly.
        Another practice that has brought the unwelcome attention of the auditors–no evidence that the physician was notified of the assessment findings and proposed POC.

        Kingsley doesn’t care as long as Nana can buy more tutus.

        December 21, 2012

        • Yeah, that whole notify the doctor thing…..

          You know how nurses always sign their name and put the date of the Recert assessment next to their signature on the 485? Well, girlfriend, let me tell you what I heard……

          Can you believe that some nurses don’t even call the doctor? At least that’s what I heard. Maybe it’s not true so don’t go spreading this around but I heard it from a very good source who made me promise not to tell you who it is….

          Seriously, I agree with you about documentation but at least some of the denials I have been seeing have actually met all standards that were in place. I guess it bothers me because when an agency transmitted an isolated assessment in 2009 really says nothing about the care they give in 2012. And it costs money and valuable resources to get the information which will result in a denial which the agency can appeal…..

          As far as documenting, if we could just get nurses to document like they should, well, hey…. we wouldn’t be employed:) I have absolutely no incentive to do so. I am only kidding.

          Obviously it is not a new problem but it is creeping up in new ways. Computerized documentation that is copied over and over is more obvious than unimaginative documentation that is handwritten. At least the doodles in the margins are in different places.

          As we go into the New Year, I think I am going to start including ‘practicing’ documentation in my classes. I am certain that you do things like offer your classes a situation that they code. I don’t recall ever seeing someone describe a patient and say, ‘here, you do the documentation.’

          Dunno. Random thoughts on the eve before Christmas Eve. Lisa, I do so hope that you have a wonderful Christmas. Post pics of Kingsley, Nana.

          December 23, 2012
  2. Danny Crudo. Pharm.D. M.S. #

    I would strongly encourage anyone receiving a recoup notice like the one described above to contact the author of this post. Because they are computer generated many may be erroneous, but even so if not handled promptly and correctly can cause other integrity programs to generate adverse activity.

    December 21, 2012
  3. Gail #

    You said, “CMS has forbidden us to discharge and readmit when a recertification assessment is performed late.” I am stuck on the word “forbidden.” Where is this explicitly spelled out?

    January 9, 2013

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