In a blog post last May, we discussed the dangers for home health providers of submitting inaccurate Outcome and Assessment Information Set (OASIS) assessments. Inaccuracies in OASIS assessments became a liability earlier this year when CMS began enforcing a condition for Medicare payment that automatically checks whether there is a corresponding OASIS assessment in the Quality Information and Evaluation System (QIES). If the OASIS assessment is missing and the claim’s receipt date is more than 40 days after the assessment completion date reported on the claim, Medicare will automatically deny the claim.
It’s been widely reported that home health agencies are experiencing increased denials when Medicare systems fail to match claims with a corresponding OASIS assessment.
In 2017, CMS issued a temporary solution to alleviate these automatic denials. Until matching errors are corrected, Medicare systems will now put home health claims without a corresponding OASIS assessment into Return to Provider (RTP) status. If Medicare returns a claim with reason code 37253, resubmit your claim following the completion of one of these actions:
- Update the HIC number so it matches on the OASIS assessment and current claim information.
- Fix the assessment completion date included in the claim treatment authorization code to match the OASIS assessment.
- Resubmit for denial using condition code 21 and Type of Bill 320 if the assessment wasn’t submitted.
It’s our understanding that CMS’s temporary solution will end once the system is updated to accept mismatched data. At that time, CMS will again issue denials rather than send claims to RTP. All claims denied prior to Oct. 6, 2017 must be appealed through redetermination.
The enforcement of CMS’ April condition of payment has negatively impacted some home health providers – there are no appeal rights for a denial received if no OASIS assessment was in the database, as there is nothing to appeal.
What’s the solution to avoid RTP and costly denied home health claims? Home health agencies must have a process to confirm the OASIS final validation reports including the Start of Care (SOC) and Follow Up/Recertification (FU) have been transmitted prior to submitting the final claim for every 60-day episode.
Thankfully, home health agencies have access to technology that can drive the OASIS submission and validation process. eSolutions has a simple solution in our OASIS Analysis tool which offers automated checks and balances to ensure you’re submitting timely accurate OASIS files, that Medicare has received and validated the files, and that you can easily track your OASIS data. Learn how OASIS Analysis can improve your home health business!