Home Health & Hospice Week

P&E round about three-fourths over, MAC reveals.

A silver lining for home health agencies under Pre-Claim Review has now evaporated, thanks to the PCR demonstration program’s halt. Probe & Educate Round 2 review will commence for providers in the PCR demo state of Illinois and continue for Florida agencies.

Reminder: Back in December, HHH Medicare Administrative Contractor Palmetto GBA announced it would begin Probe & Educate review for Florida HHAs, and the Centers for Medicare & Medicaid Services said the MACs would complete P&E Round 2 reviews of every agency nationwide in about a year (see Eli’s HCW, Vol. XXVII, No. 1).

Exemptions: A small pool of agencies are excused from P&E Round 2, however, CMS pointed out. PCR claims from Illinois agencies were excluded, as well as claims from HHAs that had 5 claims reviewed in Round 1, with zero or one claim in error. For MAC CGS, that’s about 5 percent of agencies; for Palmetto, about 15 percent, the contractors told Eli (see Eli’s HCW, Vol. XXVII, No. 3).

But then CMS suspended PCR in Illinois as of April 1, and delayed indefinitely the program’s implementation in Florida scheduled for that date.

Now, CGS and Palmetto say “while the Pre-Claim Review Demonstration for Home Health Services is paused, [they] will proceed with conducting Probe and Educate Round 2 reviews for the states of Illinois and Florida and continue conducting reviews for the state of Florida for episodes that began on or after October 1, 2016,” according to website posts. However, Palmetto “will be using a modified Probe and Educate strategy for these reviews,” it says.

“Claims that have pre-claim review decisions on file will not be selected for the reviews,” CGS says.

CGS planned to start sending out its Illinois Additional Documentation Requests about April 24 and Palmetto April 27, the MACs said.

How it works: “As ADR responses are received and reviewed, the clinician will contact the home health provider via telephone to discuss any claims that are denied or partially denied upon review,” Palmetto explains. “To expedite this process the clinician will contact the HHA the same day as the claim is reviewed. Please include the contact information for the HHA with the ADR response to help facilitate the contact.”

“Palmetto GBA will continue this modified probe and educate strategy in Florida,” it says.

Include those UTNs: The MACs and CMS have been telling agencies to go ahead and include the Unique Tracking Numbers they received for affirmed, pre-April 1 PCR requests on their claims. This is a good illustration of how those UTNs, which show the claim was approved, will help you avoid more review, experts say.

However, don’t submit the UTN if it’s for a non-affirmation, or if it’s not for “that specific beneficiary and episode of care,” Palmetto says in a new website post. “If you have received a non-affirmed UTN, submit your final claim using standard billing procedures prior to PCR,” the MAC instructs.