Home Health & Hospice Week

Do agencies think F2F review is hopeless?

The ongoing Probe & Educate medical review campaign focused on face-to-face physician encounter compliance is racking up staggering denial statistics and highlighting major problems with F2F requirements. But the initiative is also shining a light on another medical review problem that’s plagued home health agencies for decades — failure to respond timely to ADRs.

HHH Medicare Administrative Contractor CGS has told Eli that it has denied 85 percent of the claims it’s reviewed under P&E, with 30 percent of those denials due to failure to respond to the Additional Development Request for supporting documentation. MAC National Government Services has denied a whopping 97 percent of claims reviewed, it said in a recent provider call. Non-response to ADRs accounted for about 40 percent of the denials, it said. (For more details about the Probe & Educate results, see Eli’s HCW, Vol. XXV, No. 11.)

Nothing new: “Lack of response has historically been the number-one reason for ADR claim denials,” observes billing expert M. Aaron Little with BKD in Springfield, Mo. “That is, until it was eclipsed by FTF denials,” Little adds.

As is always the case, agencies may be choosing not to send in information because they feel the claim will be denied, allows nurse consultant Sharon Litwin with 5 Star Consultants in Camdenton, Mo. That’s particularly true with F2F, since the Centers for Medicare & Medicaid Services requires agencies to obtain the physician’s record and holds the physician’s documentation to difficult-to-meet standards.

Some agencies may believe it is cheaper to let the money go than to spend the staff time responding to an ADR, and then fighting a nonsensical denial, acknowledges Chicago-based regulatory consultant Rebecca Friedman Zuber.

Non-Response Yields Double Damage

“The no response to ADRs is a serious problem for home health agencies,” warns Judy Adams with Adams Home Care Consulting in Asheville, N.C.

Failing to respond to ADRs is unwise on two fronts, notes nurse consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. First, the claim at issue will obviously get denied and the agency won’t be paid for the care.

Second, “the percentage of denials against the agency adds up to an increase in the number of records audited,” Laff explains. “They will never get off of review if they do not respond.”

For example: Under the Probe & Educate campaign specifically, MACs review five HHA claims. If two or more of them are denied, then the MAC reviews another five claims, and so on. (For more on how the P&E review initiative works, see Eli’s HCW, Vol. XXIV, No. 40.)