Home Health & Hospice Week

Targeted Probe & Educate makes understanding these denial reasons critical.

Medicare is getting more serious about reviewing hospice claims, and the results may be drastic if you wind up a target of increasing medical review activities.

For example: HHH Medicare Administrative Contractor Palmetto GBA recently performed a pre-payment service-specific probe medical review on hospice claims for Routine Home Care Services, the MAC says on its website. The probe covered claims from March through May of this year in all settings.

The result: Palmetto released results for two of the probe's four regions, and the denial rates were steep. The MAC either partially or fully denied 47 percent of the 92 claims reviewed from Arkansas, New Mexico, Oklahoma, and Texas. Palmetto denied $112,158 of the $243,596 reviewed, resulting in a charge denial rate of 46 percent. And Palmetto denied 45 percent of the 92 claims it reviewed from 25 other states. The charge denial rate was a somewhat lower 36 percent in that region, however.

In both geographic areas, the top denial reasons were Physician Narrative Statement Not Present or Not Valid, No Valid Election Statement Submitted, No Plan of Care, and Documentation Submitted Does Not Support Prognosis of Six Months or Less, Palmetto reports. Failing to respond to the Additional Development Request also ranked high on the denial list.

What lies ahead: Those denial stats indicate that hospices may have a rough road ahead with the Targeted Probe & Educate medical review procedures that the Centers for Medicare & Medicaid Services had directed all MACs to use. Under TPE, hospices will stay on review through three rounds of review if they have high denial rates, and then may be referred to a fraud contractor or other authorities for scrutiny (see story, p. 300).

MAC CGS has already designated a topic for its first hospice TPE campaign (see Eli's HCW, Vol. XXVI, No. 37), and Palmetto mentions in this article that it will be launching TPE.

Silver lining: While hospices are likely to find TPE challenging, it may also have some benefits for providers, hopes Carrie Cooley, COO with Weatherbee Resources in Hyannis, Massachusetts.

Under the program, MACs are supposed to provide hospices with real-time feedback on their claims denials to help them correct similar problems in the next round, or even in the same round of review. This process, and the required time gap between review rounds, should allow hospice providers to make timely changes in forms to reduce future technical errors like missing language on the election statement or physician narrative forms, Cooley says.

Cooley is optimistic that the focus of TPE will change medical review from its more punitive approach now to a more collaborative model, which in turn will help hospices to show significant improvements in reducing denials and increasing claims paid. The TPE model's intention to decrease provider burden during probe review, reduce appeals, and improve the medical review and education process is "great news," Cooley says.