Home Health & Hospice Week

MAC is initiating takebacks based on SMRC review.

Medicare’s “probe and educate” claims reviews, focusing on certification including new face-to-face requirements, will hit episodes starting next month. You may get a hint of how the reviews will affect you by looking at another major F2F-focused review with recently announced results.

Reminder: The face-to-face physician en-counter requirement for home health patients went into effect Jan. 1, 2011. Supplemental Medical Re-view Contractor StrategicHealthSolutions reviewed 50,827 home health agency claims with dates of service from July 1, 2011, to April 30, 2013, SHS re-veals on its website. The National Association for Home Care & Hospice and other industry reps pro-tested the review, which focused on F2F requirements (see Eli’s HCW, Vol. XXIII, No. 18).

That equaled about five claims per HHA, points out financial expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif.

The claims were reviewed across all the Medicare Administrative Contractors, NAHC’s William Dombi tells Eli.

 Non-Response Accounts For More Than 1/3 Of Denials

SHS denied 49 percent of the HHA claims in the review, it says. Of the 25,021 claims denials, the SMRC denied 37 percent because HHAs did not respond to the additional development request (ADR). SHS denied the other 63 percent “because the medical records documentation did not support that HHA services were provided as billed,” the contractor says.

SHS doesn’t specify the exact reasons for the denials. However, it does warn providers about missing or illegible signatures. In such cases, “a signature log or signature attestation may also be submitted as part of the ADR response,” the contractor reminds providers.

It may be hard to draw conclusions about the upcoming F2F review from this initiative’s results, because the SMRC review was based on the now-eliminated physician narrative requirement. However, the upcoming review will require that HHAs secure documentation from physicians’ own records, which agencies fear could be an even bigger hurdle to clear.

Next Phase Of Recoupments On Deck

SHS notes that it “provided CMS with the identified improper payments” after concluding the review. CMS then directed MACs to initiate claims adjustments or recoupments “though the standards overpayment recovery process.”

Some agencies will start feeling the sting of those takebacks now. The Centers for Medicare & Medicaid Services “has provided instructions to CGS for the recovery of overpayments on approximately 2,500 claims as a result of … Phase Three, Four and Five” of the F2F review project, the MAC says. “Adjustments will soon be made by CGS.”

You can identify the adjustments by the following indicators, the MAC says:

• Type of bill = 32I
• Status/location = D B9997
• Reason code = 5SMRX (where X = 1-9)
• Remark = SMRC Phase ‘X’ (X denotes Phase 3, 4, or 5).

Recourse: The denial may not be the final word, however. “Providers can appeal a determination once they receive an overpayment demand letter from their respective MAC,” SHS says.

“Please note that the limitation on recoupment (935) applies to these adjustments,” CGS adds. “This means that if a valid first or second level appeal is received on SRMC phase 2 adjustments, CGS cannot recoup the overpayment until the decision on the redetermination and/or reconsideration is made.” 

Note: The SHS article is at www.strategichs.com/wpcms/project-y1p18y2p18-home-health-services and the CGS article is at www.cgsmedicare.com/hhh/pubs/news/2015/0715/cope29881.html.