OASIS Data Submission Failures Result in Claim Denials
NAHC Report 2010. Copyright National Association for Home Care and Hospice, Inc (www.nahc.org) .— Reprinted with permission.
NAHC Report Article
Tuesday, October 19, 2010
________________________________________ OASIS Data Submission Failures Result in Claim Denials
NAHC Urges Home Health Agencies to Analyze OASIS Data Collection and Submission The National Association for Home Care & Hospice (NAHC) recently learned that at least one contractor for the Centers for Medicare & Medicaid Services (CMS) has begun auditing home health claims for OASIS data submission during the conduct of medical review. In cases where OASIS start-of-care or recertification data for episodes under review were not submitted to the state, claims were denied in full. Up to this time, penalties for failure to submit OASIS data have been limited.
NAHC has learned that a CMS contractor is now denying claims based on a final rule published a Nov. 10, 2009 that made submission of OASIS data to the state a requirement for Medicare payment to home health agencies. The applicable provisions are found at Title 42 of the Code of Federal Regulations:
1. § 484.210 "To calculate the national prospective 60-day episode payment, CMS uses the following :…(e) OASIS assessment data and other data that account for the relative resource utilization for different HHA Medicare patient case-mix"; and
2. § 484.250 "An HHA must be 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."
The preamble to the Federal Register notice provides some insight into CMS' intentions for enforcing the regulation. CMS explained that there was no intention to change longstanding directions related to Request for Anticipated Payment submissions and OASIS completion timeframes. According to CMS, "We intend that in finalizing this policy, providers will ensure that prior to submitting a final HH PPS episode claim, a provider will have submitted an OASIS, and the HIPPS code on the final HH PPS episode claims will be consistent with the HIPPS on the OASIS validation report."
Guidance on application of OASIS data submission as a requirement for payment was issued to CMS contractors in a June 2010 Change Request (CR) update to the Medicare Program Integrity Manual, Chapter 3 Section 22.214.171.124:
A. Outcome Assessment Information Set (OASIS): Medicare's HH PPS Rate Update for CY 2010 final rule, published in the November 10, 2009 Federal Register, included a provision to require the submission of the OASIS as a condition of payment, which was codified in our regulations at 42 CFR 484.210(e). As such, beginning January 1, 2010, home health agencies (HHAs) were required to submit an OASIS as a condition for payment. Contractors may deny the claim as a result of not meeting this regulatory requirement. The assessment must be patient specific, accurate, and reflect the current health status of the patient. This status includes certain OASIS elements used for calculation of payment including documentation of clinical needs, functional status, and service utilization.
Agencies that fail to comply with this OASIS data collection and submission requirements for eligible patients are at risk of deficiency citations by Medicare state surveyors. In addition, agencies that fail to submit any OASIS data are penalized by reduction of their annual market basket update by 2 percent. However, with promulgation §484.250 as a condition of payment, entire home health claims are now subject to denial if agencies do not submit start-of-care and recertification assessments for every Medicare episode to the state. To date, information about the application of OASIS data submission requirements has been limited to Regional Home Health Intermediaries' review practices. However, adoption of OASIS data submission edits as a claims audit tool may be readily adopted by other contractors such as Zone Program Integrity Contractors and Recovery Audit Contractors in the future.
NAHC urges home health agencies to carefully analyze their OASIS data collection and submission procedures, including attention to the processes and timelines of their outside vendors. To ensure compliance with OASIS data submission as a condition of payment, agencies must submit OASIS start of care and recertification assessment data to the state prior to submitting final Medicare claims. Furthermore, agencies must ensure that the HIPPS code on the final claim matches that received on the OASIS validation report.
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