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:
NOT ONE SINGLE PATIENT WILL BENEFIT FROM THIS EXERCISE IN FUTILITY.
Please comment or email me if you have received one of these letters.