Home Health & Hospice Week

F2F continues to lead denial reasons.

Can you afford to get paid for only one out of every three Medicare claims you submit? That's what happened under the second round of the Probe & Educate medical review program, one HHH Medicare Administrative Contractor has revealed. And that may be what's in store - or worse - for providers under the new Targeted Probe & Educate campaign.

Reminder: HHH MACs ran P&E's second round last year, reviewing five claims from all HHAs nationwide except those that passed the first round of P&E with zero or one claim denials - that was 5 percent of agencies for MAC CGS and 15 percent for MAC Palmetto GBA.

Now, CGS has released results from that round. The MAC denied 4,631 claims and paid 2,277 in full, it says in an article posted to its website Jan. 29. That's a 67 percent claim denial rate.

"I am not surprised at the large percentage of denials," says Judy Adams with Adams Home Care Consulting in Durham, North Carolina. "Probe & Educate has always hit HHAs hard on denials because they focus on medical necessity."

Plus: "CGS is the second-largest MAC, so they have a large number of HHAs that will be impacted," Adams observes.

The 67 percent figure compares to a 60 percent denial rate by CGS in the first round of P&E, and a 63 percent denial rate by Palmetto in the first round (see Eli's HCW, Vol. XXVI, No. 3). Palmetto and HHH MAC National Government Services have not released round 2 stats.

The modestly higher rate for CGS's round 2 results might be due to the fact that the low-denial agencies from round 1 weren't included, notes finance expert Dave Macke with VonLehman & Co. in Ft. Wright, Kentucky.

Of course, the denials' impact hinges largely on whether they were full or partial. Based on the total claims reviewed by CGS, partial denials are 13 percent and full denials are 54 percent, a MAC spokesperson tells Eli.

In comparison: In P&E round 1, Palmetto said less than 3 percent of its denials were partial and 60 percent were full.

Here's Where AgenciesWent Wrong

CGS broke down its most common reasons for denials in round 2:

1. F2F. Face-to-face reasons were the most common cause for denials (see details in box, p. 47). They accounted for 25 percent of the overall P&E denials, CGS says.

The industry continues to have "a lot of problems" with this cumbersome requirement, Macke notes.

2. ADR non-response. The Centers for Medicare & Medicaid Services and its contractors have been harping on this issue for a while. Last September, CMS changed its provider error rate calculation to include nonresponses to Additional Development Requests (see Eli's HCW, Vol. XXVI, No. 35), and CGS and Palmetto have specified ADR nonresponse rates as Targeted Probe & Educate topics for review.

Failing to respond to ADRs is just not smart, Macke says. "I know they are time-consuming, but that ADR means money," he stresses.

3. Therapy. The reason "Documentation did not support medical necessity of therapy services accounted for approximately 457 (10 percent) of the total Probe and Educate denials," CGS reveals.

This is another longstanding target of CMS and its contractors, and the Home Health Groupings Model payment reform proposal aimed to eliminate therapy utilization from the Home Health Payment Prospective System altogether, Macke notes. It's a "variable CMS can't control," he notes.

What Can You Expect From TPE?

In its Targeted Probe & Educate program CMS launched in October, HHAs are under more medical review. But TPE might not produce the same denial stats as regular Probe & Educate, predicts billing expert M. Aaron Little with BKD in Springfield, Missouri.

"TPE is such a different process," Little tells Eli. "Since TPE is targeted at specific providers - and it's a bigger sample than what was taken for P&E - then I think it's possible that the denial percentage could look very different." TPE will sample up to 40 claims per provider, versus five claims under regular Probe & Educate.

On one hand: Providers may have learned some documentation lessons under the two Probe & Educate rounds, and their claims may hold up to scrutiny better under TPE, Little forecasts. That would mean a lower denial rate.

On the other hand: HHAs that struggled the most under P&E may wind up on the top of the TPE target list and continue to "fail" their audits, resulting in a higher denial rate, Little speculates.

Note: The article is at www.cgsmedicare.com/hhh/pubs/news/2018/0118/cope6108.html.