Home Health & Hospice Week

Review can ramp up to hundreds of your claims relatively quickly.

Wondering how the new “probe and educate” review process for face-to-face requirements will work for episodes beginning Aug. 1 or later? You can get some clues from a similar initiative Medicare imposed on hospitals.

Home health agencies will begin seeing additional development requests for F2F Oct. 1, the Centers for Medicare & Medicaid Services recently announced (see story, p. 154). But other details are sketchy so far. Take a look at these components of the hospital probe and educate program for hints:

• Medicare Administrative Contractors sampled 10 or 25 claims per hospital, depending on size, according to a March 2014 question-and-answer set from CMS.

• CMS sorted providers into three categories defined in MLN Matters article SE1403 as “Minor” — 0-1 errors out of 10 claims or 0-2 errors out of 25; “Moderate-Significant” — 2-6 errors out of 10 or 3-13 errors out of 25; and “Major” — 7+ errors out of 10 or 14+ errors out of 25.

• When MACs found problems, they denied the claims, as they would in a regular pre-pay probe. But unlike in a regular probe, they furnished detailed information on the denials to hospitals.

• MACs sent “detailed results” letters to hospitals with denied claims, CMS notes in the MLN Matters article. In those letters, they offered one-on-one phone calls to further discuss the denials if desired.

• The MACs’ made “individualized phone calls” to providers with either moderate-significant or major concerns. During such calls, the MACs discussed the reasons for denial, provided pertinent education and reference materials, and answered questions, CMS says in the Q&A.

• When MACs identified no issues during the probe review, the MAC ceased further such reviews for the time period, CMS says in the Q&A.

• When probe results landed hospitals in the moderate-significant or major concern categories, they were subject to more review — another small review at first, then review of 100 to 250 claims if denial rates did not improve, CMS says in the Q&A.

One bright spot: CMS instructed contractors not to review the 2 midnight issue for hospitals outside of the P&E program, according to the Q&A. Home health agencies may benefit from a similar directive for F2F, observers hope.

Note: CMS’s MLN Matters article about the hospital P&E initiative is at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/se1403.pdf  and the Q&A is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf