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Posts tagged ‘OASIS’

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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Change on the Horizon

The 2015 update to  Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information.  Here’s the bullet points.

Reduction in Payment

No news here.  Everyone was expecting a decrease in payment.  It comes to approximately $81.00 subtracted from the standard episode rate.  The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate.  In contrast, the per visit rate has gone up slightly. 

Face to Face documentation requirements

A face-to-face document is still required but the narrative section has been removed effective January 1, 2015.  Within the regulations the effect of the Face-to-Face requirement has been described as follows:

  • The error rate for home health claims was calculated to be 17.5 percent.
  • The majority of home health improper payments were due to “insufficient
    documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
    required by §424.22(a)(1)(v).
    • CMS-1611-F  Page 37

ImportantAll episodes beginning with an OASIS Start of Care assessment will require  Face-to-Face documentation.  While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error.  This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing. 

MD/hospital documentation:  The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility.  This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation.  Do not wait until 2015 to add getting the MD records in the chart prior to billing.

Interesting and Important:  I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it.   This is in stark contrast to not being able to help the physician compose the narrative.  Read for yourself and feel free offer your own opinion.

The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.

The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.

End in Sight

Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care.  I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either.  Regardless of who saw what, the directive is in place.  Be careful of ‘statutory’ reasons for denial.  This has the potential to be like dates, signatures, etc.  Once it is identified that a recertification did not meet requirements, a full denial can be issued.


There are some changes to the payment calculations.  I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference.  Consider that a cry for help.

Data Submission

There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data.  Nobody knew what that meant.  Did it mean penalties for no data submission or less than 100% data submission?  It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years. 

Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word.  If you are not sure of your data submission status, call us now. You need help.

Value Based Purchasing

Value Based Purchasing is recycled Pay-for-Performance.  The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor.  Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick.  Keep your ears to the ground for more information.

These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff.  Take some time and read through the comments and look at some of the data.  We will be doing so as well and posting anything interesting or important we find.

Good luck.  It’s always an adventure when the regulations are changed.


But Our Survey was Perfect!

The state has come through and scrutinized every piece of paper in your office, gone on multiple home visits and even complimented you on your Infection Control Program.  There’s absolutely no reason to be concerned when some ADRs are received from Medicare.  How could an agency as perfect as yours be denied payment?

It happens every day.  Trust me.  I hear about perfect surveys and denials in the same sentence almost every day.

State regulations often follow the Medicare Conditions of Participation.  If your survey was perfect or even just good, you have likely met the CoP’s.  However, off to the side, in another area of the manual are the Medicare Conditions for Payment.  They are separate and apart from the CoP’s because not all payor sources have these requirements for payment. 

They are:

  • The patient is confined to the home
  • The patient is under the care of a physician (or as we say in the south, under the doctor)
  • The patient has a need for recurring, intermittent skilled care.
  • A Face-to-Face Encounter must occur within a designated time frame
  • The patient is an eligible beneficiary
  • OASIS data has been collected and submitted.
  • The agency is certified by Medicare.

Most patients meet the homebound criteria but many patients do not have homebound criteria documented well enough to warrant payment.  In case you missed it, here is a post about how to document homebound status.   

The patient is under the care of a physician should be obvious, right?  Not so fast, grasshoppers.  Not just any physician counts.  It has to be one that is licensed in your state or your state must allow physicians from nearby counties in another state to write orders.  Each state is different so read your physician practice acts and call the board of medicine if you still aren’t clear. 

The way that Medicare determines that a patient is under the care of a physician is by looking at signatures.   For years, we were told that if the physician failed to date his or her signature, we could simply enter the date the signed plan of care was received by the agency.  They changed their minds on that one a few years ago but not everyone got the memo, apparently.  Everyone in the agency who sees plans of care on a regular basis should be taught to look for dated signatures.  The earlier you find an undated signature, the more likely the physician will be able to sign an attestation statement with confidence.

Recurring, intermittent services sounds like someone is trying to confuse you.  In short, you may not see a patient indefinitely and you may not arrange to see a patient only once.

Daily nursing visits must have a written ‘end in sight’ to daily skilled nursing care included in the documentation.  The single exception to this rule is daily visits for insulin injections.   You can document this anywhere but I like to see it under the frequency or in the goals section.  Similarly, you may not plan to visit a patient once.  Physicians may call and ask for you to go to the house to remove sutures or administer a flu vaccine.  These visits would not be covered under the Medicare home care benefit although you can give a flu shot.  If a patient dies, moves out of town or refuses services after the admission visit, you may bill for it because you fully expected to see the patient again.

I think we have covered, recovered and stripped bare the Face-to-Face documentation requirements in prior posts.  If you continue to have questions, read here

Skilled care is defined in the Medicare Benefits Manual, chapter 7.   I always have a copy on my iPad and my desktop but whenever I can, I go to the online version because changes are fairly frequent.  You can identify the changes by the red font.

Everyone checks eligibility right?  I seldom see a problem with that but when one occurs, it occurs in a very big way.  Usually, an unfortunate soul without Medicare or insurance will borrow someone else’s card.  Although you are completely clueless, it is still non-billable.  That means you have to give the money back.  If you find out about it before Medicare does, you have 60 days before the money is considered fraudulent (that applies to all overpayments).  Whenever possible, check identification on admission.

It seems that until recently, agencies sent OASIS data in one direction and claims in another and the two never met up and the penalty for not submitting OASIS data was very scarcely enforced.  At some point, the OIG got wind of this and jumped all over Medicare in a long and boring report last year.  Now now you will be denied on an ADR if the OASIS data has not been submitted. 

I think you will know if ever your agency becomes decertified so let’s just skip that one.  (Hint:  one big clue is the lack of payment.)

Your state surveyors do not know much at all about billing.  The Face-to-Face requirement is not a requirement for licensure.  In all likelihood, you probably know more about OASIS and coding than a surveyor does because they do not do it every day.  The state really doesn’t survey your length of stay.  The state wants to know if you meet the basic requirements to provide care for patients.  If you are still confused, consider that the state employees are paid by state taxes to protect the citizens of the state.  Medicare pays contractors to protect the trust funds (large piles of money) used to pay for the care.

If you have a perfect survey, it means that you are doing many things right.  In fact, if you get in trouble with your state agency, there will come a point in time where they will communicate with Medicare and your provider number will be at risk.  I’ve only seen that happen a few times by people who do not read stuff like this. 

Now think about all the reasons agencies have claims denied.  They are not included in your state survey.  And that is how you can have a perfect survey and still get denials or worse. 

Now you know. 

Questions and comments are always welcome.


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. 

Data Submission

Have you submitted your OASIS data?  All of it?  Have you looked at your validation reports in great detail to ensure that there was not one fatal error that may have been overlooked?

What about your HHCAHPS data?  Have you been diligent about submitting it?  If your agency had less than 60 patients from March 31 through April 1, have you submitted an exemption request on the HHCAHPS website?

If you are not 100 percent sure about these answers, it might be a really good time to find out and ensure that  you have met your data submission requirements.  You will be penalized if your OASIS and/or HHCAHPS data isn’t submitted.

The penalty sounds modest enough – 2 percent.  But unless you are really good at doing business or really bad at taking care of patients, that 2 percent could be anywhere from 20 to 50 percent of your margin.  If you are really good at taking care of patients and mediocre in the business area, this modest 2% could devastate you.

The Medicare Guidance, which can be found here, reads:

In calendar year 2007 and each subsequent year, if a home health agency does not submit required quality data, their payment rates for the year are reduced by 2 percentage points.

Notice the reference to the year 2007?  The actual reg has been in effect even longer than that and only a couple of agencies here and there were penalized.  The Office of the Inspector General took notice of that earlier in the year and penalties are on the way.  The  Medicare Administrative Contractors (MAC’s – formerly FI’s also known as Palmetto, Pinnacle, etc.) have received these instructions straight from CMS:

Each fall, Medicare contractors with home health workloads will receive a technical direction letter (TDL) which provides a list of HHAs that have not submitted the required OASIS and/or HHCAHPS data during the established timeframes. These Medicare contractors shall review their paid claims history for claims which have:

  • a provider on the (naughty) list
  • Dates of service from July of the previous year
  • Beneficiaries over 18

Here’s the part that is really good:

If the contractor finds any such claims, the contractor shall notify the HHAs that they have been identified as not being in compliance with the requirement of submitting quality data and are scheduled to have Medicare payments to their agency reduced by 2%.

I have yet to see where a threshold for compliance has been set.  It does not say if the majority of data was submitted or if 90 percent of the data was received.

It also doesn’t say how they are going to identify the providers.  Will they look for gaps longer than 3o days between submissions?

My experience is not reassuring.  Agencies have received deficiency notices for late submissions but there have a number of times over the past few years when no data was submitted.  Nothing has been received when no data was submitted.

In one agency, a young lady had indeed submitted the data and placed the validation reports in a binder just as she was told.  Her instructions should have included reading the reports.  Every single assessment had been rejected for a period of six months.

Several times in several different agencies, the person responsible for data submission left employment.  When they did, nobody picked up the relatively insignificant task of transmitting data.

If I were an administrator or a Director, you can prevent disaster by:

  • Requiring OASIS data to be submitted every two weeks.  It is not unheard of that uploading data is difficult and time consuming
  • Require written confirmation that the task was done.
  • If you use outlook, put a recurring reminder with an email that goes out two days before data is to be uploaded.  That way, if you forget about all this a year from now and the person uploading the data leaves, you will get a bounced email
  • Actually look at validation reports and ensure they are being addressed.
  • A system of verifying with your HHCAHPS vendor that submission of data has occurred according to your contract.

If you are a field nurse or someone else who doesn’t deal with OASIS transmission, don’t hesitate to bring a copy of this to the people who do to remind them of the importance of it.  If they are offended, walk it off as my son’s coaches used to say.  I can pretty much guarantee that you will not get a raise next year if your agency takes a 2 percent hit.