Home Health & Hospice Week

Plus: MAC denies $2.1 million in GIP claims.

One HHH Medicare Administrative Contractor seems to be wasting no time resuming post-payment medical review of claims from the COVID-19 public health emergency.

The Centers for Medicare & Medicaid Services recently announced that it would fire up post-payment medical review for claims that providers submitted during the COVID era (see HCW by AAPC, Vol. XXX, No. 21). Now Palmetto GBA has released results from two such reviews.

No. 1: Palmetto performed “service-specific postpayment probe review” on 3,136 claims processed from January through March 2021, it says. “A total of 449 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 14.32 percent,” the MAC reports on its website. About $931,000 of the $7.3 million dollars reviewed were denied, “resulting in a charge denial rate of 12.73 percent,” Palmetto reveals.

The top reason for denials, by far at 50 percent, was Face-to- Face Encounter Requirements Not Met (5FF2F/5TF2F), the MAC says. The next-most-common reasons were No Plan of Care or Certification (5F023/5T023) at 20 percent, No Initial OASIS/OASIS Present for SCIC HIPPS Code (5FNOA/5ANOA) at 8 percent, Dependent Services Denied- (Qualifying Service Denied Medically) (5TDSD/5ADSD) at 6 percent, and Documentation Submitted Was Insufficient to Support That the Skilled Nurse Service(S) Billed Was/Were Reasonable and Necessary (5F041/5A041) at 4 percent.

No. 2: Palmetto also performed a “service-specific postpayment probe review” on 1,669 Hospice General Inpatient Care (GIP) claims processed from January through March 2021, it says. “A total of … 331 of the claims either completely or partially denied, resulting in an overall claim denial rate of 19.48 percent,” the MAC reports. About $2.1 million of the $13.5 million reviewed was denied, “resulting in a charge denial rate of 15.29 percent,” Palmetto tells providers.

Reasons for the GIP denials were less lopsided, with 26 percent due to Services Not Reasonable and Necessary (5CF91/5CF91); 23 percent due to The Hospice Election Does Not Meet Statutory/Regulatory Requirements (5FNER/5CNER); 14 percent due to Physician Narrative Statement Not Present or Not Valid (5FFH9/5CFH9); 6 percent due to Initial Certification Not Timely (5FFH6/5CFH6); and 5 percent due to Face-to-Face Encounter Requirements Not Met (5FFTF/5CFTF).