Home Health & Hospice Week

MAC to discontinue one therapy-focused probe.

Face-to-face physician encounter denials are not easing following Medicare’s medical review crackdown on the issue — in fact, the opposite appears to be occurring.

In its latest review of two therapy-focused probes, HHH Medicare Administrative Contractor Palmetto GBA reveals that the rate of F2F denials has climbed since the results it reported three months ago.

Then: Back in October, Palmetto reported that F2F was by far the most common reason for denial in two probes it conducted — one for claims with 2CGK* HIPPS codes and one for claims with 1BGP*. (HIPPS code 2CGK* represents an episode with 14-15 therapy visits and 1BGP represents an episode with 11-13 therapy visits.) In one region F2F accounted for 100 percent of the denials. Two regions saw F2F denial percentages in the 50s, two in the 70s and three in the 80s, Palmetto reported (see Eli’s HCW, Vol. XXII, No. 38).

Now: In the latest quarter, three of Palmet-to’s regions had F2F denial rates in the 60s, four in the 80s, and one had a 99 percent F2F denial rate, the MAC says on its website.

The F2F denial burden is crushing HHAs, providers tell Eli.

Not F2F alone: While F2F denials are commanding agencies’ attention, other denial reasons have not gone away. Medical necessity and missing technical components such as physicians’ dated signatures and missing OASIS are also plaguing agencies, Palmetto’s latest statistics show. (See related story, p. 52, for preventing these types of denials.)

And the second-biggest reason for denials should be the easiest to avoid — failing to respond to the Additional Development Request (ADR). Under Palmetto’s 2CGK* probe in its Southeast region, more than 30 percent of the denials were due to agencies failing to submit records, the MAC says.

HHAs Excused From RAC Prepay Review Demo

HHAs are catching a break with Palmetto’s higher-therapy 2CGK* edits, at least. "The four service-specific HIPPS Code 2CGK* edits have not produced sufficient claim volume, despite historical trending, to identify any providers to progress to provider-specific edit," Palmetto notes. Therefore, the probe "will be discontinued."

However: "If future significant billing aberrancies are identified, provider-specific medical review may be initiated," Palmetto warns.

The MAC plans to continue its 1BGP* edits, it says.

Another break: The Centers for Medicare & Medicaid Services "has removed the edits for home health claims under the recovery audit (RA) prepayment review demonstration." MAC National Government Services says in a message to providers. "No home health claims generated additional development requests (ADRs) under this demonstration."

Back in the summer of 2012, CMS had notified providers that RACs would start the prepay review demo that August (see Eli’s HCW, Vol. XXI, No. 30). "The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments," CMS explained. The reviews would focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. "This demonstration will also help lower the error rate by preventing improper payments rather than the traditional ‘pay and chase’ methods of looking for improper payments after they occur," the agency said.

Note: For more information and advice on F2F denials, you can purchase Eli’s Face-To-Face Documentation Handbook at www.codinginstitute.com/face-to-face-documentation-handbook-2014.html, or by calling 1-800-508-2582.