Home Health & Hospice Week

One MAC’s rate is a staggering 97 percent.

Your reimbursement may be doomed under face-to-face physician encounter rules that took effect last year, even when you know the ropes.

The proof: In the Probe & Educate medical review initiative Medicare launched at the end of last year, two Medicare Administrative Contractors have denied more than 90 percent of claims reviewed so far. National Government Services recently said it has denied 300 of 309 claims reviewed under P&E — 97 percent (see Eli’s HCW, Vol. XXV, No. 10). And CGS tells Eli that it has denied 808 of 904 claims reviewed — 85 percent. Combined, the NGS and CGS reviewers have denied 92 percent of the claims they’ve reviewed thus far. (That includes partial denials, CGS points out.)

Palmetto GBA tells Eli it is not releasing P&E denial stats yet. “It would be premature at this time to release HH Probe & Educate review results due to the small sample size assessed,” a Palmetto spokesperson says. “The limited number of HH P&E reviews to date do not permit a reliable estimate of the actual result once all claims have been reviewed.” Also, results wouldn’t include appeals, the MAC points out in a statement. Palmetto will issue results on its website later, it adds.

In a breakdown furnished to Eli, CGS ranks its P&E denial reasons:

# 1 denial reason: Certification issues — 57 percent (breakdown below)
# 2 denial reason: No response to ADR — 30 percent
# 3 denial reason: Medical Necessity of therapy services — 7 percent.

Of the 57 percent of claims CGS denied due to certification issues, the reasons were:

• F2F missing/incomplete/invalid ( 91 percent)
• Untimely POC/certification (2 percent)
• POC/Certification not signed (2 percent)
• Missing certification/POC (2 percent)
• Recertification estimate missing (1 percent)
• Initial cert missing/invalid (1 percent).

Reminder: The Centers for Medicare & Medicaid Services implemented new F2F documentation rules in January 2015. Under the new requirements, physicians no longer have to furnish a narrative, but they now must proffer their own clinical records to substantiate a patient’s home care stay. (See box, p. 82, for the five items the physician’s clinical record must contain.)