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New Automated Denials Coming Soon

Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner.  His contact information follows this post.

John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea.  It speaks to a new way that agencies can be denied without a lot of trouble.  There are links to supporting information an this needs to be shared with your entire agency.

Dear Clients:

 The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system.  This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process.  (Julianne’s note:  often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode.  Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)

Title:  Denial of Home Health Payments When  Required Patient Assessment Is Not Received – Additional Information


This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.


In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.


Don’t cost yourself money by not paying attention to the details.  This has always been a requirement under PPS, just a loosely (if at all) enforced regulation.  That is changing effective April 1st.  Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’.  Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).

In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.


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3 Comments Post a comment
  1. Michelle Funk #

    Where the hell is NAHC in fighting this??? How is this ever going to be doable with the QIES system as antiquated and difficult to use? We process about 200 admissions per month, we are a small agency with two billers. I feel like these people are sitting in a room just dreaming of ways to destroy our industry, WHICH IS THE MOST COST EFFECTIVE form of healthcare, even taking into account the fraud that has taken place. I just don’t understand.

    March 28, 2017

    • I can’t answer for NACH but I wonder if computer vendors might add a ‘print episode’ option that includes all relevant OASIS assessments.

      Look at it like this. A bunch of elected officials can’t tell the elderly they are reducing benefits. So they don’t. But they do approve all these measures to fight ‘fraud and abuse’. Everyone hates fraud and abuse but does omitting an assessment really count?

      March 28, 2017
  2. funkshore #

    It isn’t even about an omitted assessment. The QIES system is beyond antiquated and reviewing the validation reports, fixing errors and resubmitting OASIS, then repeating the process is so very labor intensive and, although I believe in clean data, often the priority of working the error report falls in an over-taxed workforce. If the QIES system was somehow searchable by an automatic integrated process on the provider side, it would make sense. This is nothing but a “gotcha” scheme. If they can integrate systems between QIES and MACs to flag for denial, there must be something that providers can do that would be more automated, thus support compliance. It seems to me that there in-lies the issue, they want our money, not our compliance. SO VERY SAD….

    March 28, 2017

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