Home Health & Hospice Week

You may receive even more medical review requests, thanks to a new CERT project.

"To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto GBA was recently funded by CMS to undertake additional medical review projects that involve medical review of and education for certain ... claims that contributed to the majority of the J11 MAC CERT payment errors," Palmetto says on its website. That includes home health claims.

"Providers selected for education and/or medical review are selected based on the frequency of their billings" for the relevant services, the MAC says. "Palmetto GBA's educational and review efforts will primarily focus on reducing payment errors from insufficient documentation and improper coding. Providers will receive written results of the project's findings if being selected for medical review."

Right now the project is focusing on prepayment review, but could include post-payment review later, Palmetto says in a question-and-answer set about the project. You'll know the review is for the CERT project because "the ADR will state the claims were selected as a result of a 'special study' or 'increased medical review," the MAC explains.

The ADRs will be subject to the usual deadlines and appeal requirements. Remember, "claims that were denied due to lack of documentation cannot be resubmitted as a new claim," Palmetto instructs. "Resubmitting a denied claim as a new claim is considered fraudulent billing practice." Instead, you have to submit a usual reopening appeal request.

Common reasons for denial include missing, illegible, or stamped signature; missing or unsigned physician's orders; illegible documentation; and failure to submit documentation for all dates requested, Palmetto lists.