Home Health & Hospice Week

Are you taking these 4 steps before submitting every claim?

No matter which HHH Medicare Administrative Contractor is conducting your Targeted Probe & Educate review, face-to-face physician encounter requirements are most likely to be the reason your claim gets denied.

Recent TPE results from MACs Palmetto GBA and CGS show F2F ranks No. 1 at both contractors for denial reasons. CGS listed the reason as accounting for 25 percent of its denials in its latest results, while Palmetto says F2F made up 16 percent of its TPE denials.

Rounding out Palmetto’s top 5 TPE denial reasons are:

• 5F023/5T023 — No Plan of Care or

Certification, 14 percent 5F072/5T072 — No Physician’s Order for Services or More than Ordered, 13 percent

• 5F070-5T070 — No Documentation of Services Rendered, 12 percent
• 5F301/5A301 — Information Provided

Does Not Support the Medical Necessity for Therapy Services, 8 percent.

Directly comparing the MACs’ denial reasons can be tricky, because they aren’t reported in the same way. But CGS also lists a denial reason addressing Plan of Care problems at 7 percent, physician orders at 13 percent, and missing documentation at 11 percent.

Differences: CGS reports a missing or invalid recertification estimate as accounting for 9 percent of TPE denials. Palmetto’s therapy reason doesn’t show up on CGS’s top 5 list.

Some of these denial reasons are cause for worry, says Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. For example, determining an initial certification is invalid “is hard on a provider,” Olson tells Eli. They “do a whole episode and get the final claim denied because of the certification.”

Often, when providers don’t submit documentation in response to an Additional Development Request, “there is a good chance the provider did not receive the request,” Olson says. Providers relying on mailed ADRs will have limited response time at best, and won’t receive a notice at worst.

Tip: Online monitoring for ADRs is of tremendous benefit, Olson judges.

What Reasons Account For The Other 35%?

Even though both CGS and Palmetto GBA have released their top 5 denial reasons, a lot of denial information still is left unrevealed, industry experts note.

CGS’s top 5 list accounts for 65 percent of its TPE denials, and Palmetto’s 63 percent. Getting a partial list makes it “difficult to get the full scope of denial reasons,” notes Joe Osentoski with QIRT in Troy, Michigan. “That leaves a considerable amount of unknown denials,” which may include reasons such as homebound and reasonable and necessary service, he points out.

Given the TPE failure rate, “the best defense against Targeted Probe and Educate is to not be a target,” Osentoski stresses.

Check these 4 boxes: “Vet the face-to-face encounter documents in the record, send in ADRs timely, check certification requirements are met prior to final billing, and check that all orders/plan of care requirements are met before final billing,” Osentoski advises. “Those remain the best ways to address the current TPE edits.”

Note: More tips for avoiding the top TPE denials are in Palmetto’s results article at www.palmettogba.com/palmetto/providers.nsf/vMasterDID/B6YPUS7372.