Home Health & Hospice Week

Good news: One of the most common denial reasons will go away in the new year.

You don’t have to experience Targeted Probe and Educate review first-hand to learn some lessons from the program. Take a look at the top denials for clues on where to direct your resources.

From Oct. 1, 2017, to Sept. 30, 2018, TPE reviewers for HHH Medicare Administrative Contractor CGS cite these reasons most often for denying claims:

1. Face-to-Face missing/incomplete/untimely — 25 percent of denials. Common problems were that the actual F2F encounter document was not submitted; the certifying physician did not document the date of the F2F encounter; the community physician was not identified when a physician who would not be following the patient after discharge signed the certification; and the required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification.

2. Initial certification invalid — 13 percent. See an example of a valid cert statement at www.cgsmedicare.com/hhh/pubs/news/2018/0118/cope5731.html.

3. Medical records were not received — 11 percent. In the latest quarter, CGS noted that in 30 of the 152 probes it conducted (20 percent), providers didn’t respond to Additional Development Requests. “The non-response is inexcusable and feeds the ‘waste, fraud, and abuse’ narrative,” says consultant Joe Osentoski with QIRT in Troy, Michigan.

4. Recertification estimate missing/invalid — 9 percent. It’s no surprise this is on the list, since CGS “often receives calls from providers asking about the recertification requirement for physicians to include an estimate of how much longer the skilled services will be required,” the MAC notes on its website. But the good news is that the requirement shouldn’t dog HHAs much longer. The 2019 HH PPS final rule eliminates the requirement, as of Jan. 1, 2019, that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care, according to the rule published in the Nov. 13 Federal Register (see Eli’s HCW, Vol. XXVII, No. 38).

5. Plan of care missing/invalid — 7 percent. A fact sheet on this requirement is at www.cgsmedicare.com/hhh/education/materials/pdf/hh_5hpln-5hord_factsheet.pdf.

What else? “The five top denials account for 65 percent of the total,” points out Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. “I would like to know what the remaining 35 percent of issues are.”

Note: You can find out about TPE hot topics from HHH Medicare Administrative Contractor Palmetto GBA in quarterly teleconferences throughout the year. The next one is March 4. Dial-in information is at www.palmettogba.com/event/pgbaevent.nsf/SeriesDetails.xsp?EventID=B74TM73304.