Home Health & Hospice Week

Targeted Probe and Educate medical review is back, and it’s soaking up agencies’ precious time and resources. But before TPE, post-payment medical review from the HHH Medicare Administrative Contractors resumed — and its results are highlighting home health and hospice agencies’ problem areas.

Recap: The Centers for Medicare & Medicaid Services paused the TPE program when COVID-19 hit in March 2020, saying it would stay paused for the duration of the COVID Public Health Emergency. But in August, CMS announced it would resume TPE, later confirming it would have a Sept. 1 start date (see HCW by AAPC, Vol. XXX, No. 32). CMS also announced in early June that it would resume postpayment medical review starting in August (see HCW by AAPC, Vol. XXX, No. 31).

Now two HHH MACs have released their postpayment review results of claims from April through June of 2021. The contractors have taken very different approaches in summarizing their review data, however, so an apples-to-apples comparison isn’t apparent.

Palmetto offers consolidated review figures as well as numbers broken down by state. CGS, on the other hand, has posted figures separated by service-specific review topics.

Hospice LOS, GIP Claims Rack Up Alarming Denial Rates

Palmetto reviewed 2,517 home health claims in the period, denying 434 of them for a 17.2 percent claims denial rate, it reports. That includes both full and partial denials. And 141 of the claims were auto-denied, Palmetto adds.

The charge denial rate is slightly lower for those claims, with Palmetto denying about $947,000 of $6.2 million reviewed for a rate of 15.3 percent, the MAC says in a new post on its website.

The top reason for Palmetto’s denials is “Face-to-Face Encounter Requirements Not Met” (denial code 5FF2F/ 5TF2F) at 50 percent of the denials, the MAC reveals. The next-most-common denial reason isn’t even close — “No Plan of Care or Certification” (5F023/5T023) at 20 percent.

Rounding out the top five denial reasons are “No Initial OASIS/OASIS Present for SCIC HIPPS Code” (5FNOA/5ANOA) at 13.5 percent, “The Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(s) Billed Was/Were Reasonable and Necessary” (5F041/5A041) at 5.5 percent, and “Medical Review HIPPS Code Change Due to Partial Denial of Therapy” (5CHG3/5CHG3) at 2.5 percent.

In the state-by-state breakdown, the state with the highest rate of claims denials is New Mexico at 35 percent, followed by an “other states” group at 29.8 percent, and Indiana at 20 percent. Those states have slightly lower charge denial rates of 30.8 percent, 26.9 percent, and 18.3 percent, respectively.

The states with the lowest claims denials rates for the period are Arkansas (6 percent) and Georgia (7.5 percent). Their charge denial rates are 4 percent and 7.2 percent, respectively.

In contrast, CGS breaks out results by service-specific topic. It reviewed a total of 960 home health claims from the April-through-June period under the Home Health Medical Necessity topic, denying 430 of them for a claims denial rate of 48 percent. The MAC doesn’t differentiate between partial and full denials.

The top reason was “documentation not received/ received untimely,” CGS notes. Providers didn’t respond for 204 of the 960 claims reviewed.

Under the Hospice Length of Stay Greater Than 730 Days topic, CGS denied 89 of 132 claims reviewed, for a whopping 67 percent denial rate. Only 16 of those claims had no response. The top denial reason is lack of support for six-month terminal prognosis.

For the General Inpatient care LOS equal to or greater than seven days topic, CGS again denied 89 claims, this time out of 128 reviewed for a 69.5 percent denial rate. A slightly higher 19 claims had so response. The top denial reason is GIP not reasonable and necessary.