Home Health & Hospice Week

Will denial rate north of 90% persist?

Medicare gave Florida home health agencies yet another lump of coal in their stockings right before Christmas — the next round of the Probe & Educate medical review campaign aimed at Face-to-Face compliance.

“Palmetto GBA is conducting pre-payment reviews of home health claims submitted by home health providers in Florida for episodes that began on or after October 1, 2016,” the HHH Medicare Administrative Contractor said in a Dec. 19 website post. “The first additional documentation requests (ADRs) will be sent on or about December 27, 2016.”

HHAs outside of Florida aren’t off the hook, however. The Centers for Medicare & Medicaid Services “is directing Home Heath MACs to select a sample of 5 claims for pre-payment review for from each HHA within their jurisdiction” under Probe & Educate, the agency says in a revised MLN Matters article about the campaign. CMS says it expects the MACs to take up a year to complete the activity, however, so your turn may not come for a while.

Exception: CMS and its MACs will excuse from Round 2 review agencies that received errors on no or one claim out of the five reviewed in the last round of P&E, MLN Matters Article No. 1635 explains.

Last spring, MACs National Government Services and CGS reported preliminary sky-high denial rates under Probe & Educate of 97 percent and 85 percent, respectively (see Eli’s HCW, Vol. XXV, No. 11).

With Pre-Claim Review and other types of review underway, agencies might see denial rates drop in this round. But with last round’s top performers excused, they might get even worse.

How it will work: “As ADR responses are received and reviewed the [reviewing] clinician will contact the home health provider via telephone to discuss any claims that are denied or partially denied upon review,” Palmetto explains. “To expedite this process the clinician will contact the HHA the same day as the claim is reviewed.”

Important: “Please include the contact information for the HHA with the ADR response to help facilitate the contact,” Palmetto instructs.

Note: The MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1635.pdf.