Medicare determines payments of home care claims using case-mix groups derived from the OASIS assessments of the beneficiary. Home care agencies submit the case-mix groups on their claims as a HIPPS code. OASIS documents are submitted to a national repository and claims are submitted and processed by the Fiscal Intermediary Shared System (FISS). Until now, the transmission of OASIS data and the claims processing systems were entirely separate. No comparison between the OASIS information and the claim data was performed. In 2012 the OIG identified this as a payment vulnerability and prompted CMS to implement systems that would allow for a comparison between the OASIS and the claim information prior to finalizing claims for payment.
After years of development this system is finally in place. Beginning April 1, 2015 the FISS system will validate the HIPPS code on submitted claims against OASIS data. If it is found that the HIPPS code on the claim is different than the HIPPS code on the OASIS information on file the claims processing system will pay the claim based on the HIPPS code from the OASIS document. This additional point of data validation is expected to occur in the normal 14 day final claim processing time frame and is not expected to delay payments. At this time if no OASIS information is on file the claim will process and pay based on the HIPPS code reported on the claim.
Federal regulations require the submission of OASIS data as a condition of payment. If during medical review no OASIS information is found on file the claim is denied. As mentioned above the claims processing system will not deny claims if no OASIS information is found but the OIG recommends that CMS use this claims matching process to deny home care claims when the OASIS information is not on file during this data validation check. CMS plans to enforce this requirement in the earliest available system release.
Follow the link below to the Med Learn Matters article describing these changes. In this article you will find details regarding new DDE fields created to accommodate this change as well as remittance advice remark codes that will be applied to claims impacted by this new requirement.