Home Health & Hospice Week

F2F problems dog P&E claims.

As Medicare kicks Round 2 of the Probe & Educate medical review program into gear, home health agencies may learn some important lessons from Round 1.

Denial rates for Round 1 were pretty steep, with HHH Medicare Administrative Contractor CGS now reporting 2,755 of 4,621 claims reviewed under the program denied either fully or partially that’s nearly 60 percent. But at least that figure is down from the 85 percent denial rate CGS reported in the early days of Round 1 (see Eli’s HCW, Vol. XXV, No. 11).

MAC Palmetto GBA tells Eli it has similar denial statistics — 60 percent of claims reviewed in Round 1 were fully denied and another 2.6 percent were partially denied. Palmetto did not release preliminary denial statics during the earlier round.

MAC National Government Services has not responded to Eli’s requests for Round 1 data, but it reported a staggering 97 percent denial rate in the early days of P&E.

The MACs hope to see those figures improve as HHAs spend more time understanding the Face-To-Face physician encounter documentation requirements. The Pre-Claim Review demonstration project in Illinois, which will also launch in Florida April 1, may help with that.

“CGS has seen a significant improvement in denial rates for providers in the state of Illinois since the implementation of the Pre-Claim Review Demonstration in comparison to Round 1 Probe and Educate denial rates,” a MAC spokesperson points out. However, the lessons learned by Illinois HHAs won’t necessarily affect P&E Round 2 directly. PCR providers “are not included in Round 2,” a Palmetto representative says.

Also exempt: The Centers for Medicare & Medicaid Services has specified that Round 2 will be “excluding those providers who had 5 claims reviewed in Round 1, with zero or one claim in error” (see Eli’s HCW, Vol. XXVI, No. 1). For CGS, that will be about 5 percent of agencies; for Palmetto, 15 percent, the MACs say.

Hopefully Round 1 education will make a difference with Round 2’s denial rates as well, Palmetto says. The MAC “would expect to see improvement from those providers that received one-on-one education during round one or [that] have participated in various other education opportunities made available to home health agencies.”