Home Health & Hospice Week

HHAs have a chance to show their face-to-face documentation has improved.

A Palmetto GBA representative says the MAC “has completed reviews on approximately 75 percent of the home health claims sample” for Probe & Educate Round 2. “The remaining approximate 25 percent is comprised of ADR requests pending response by the provider, ADR responses pending review by Palmetto GBA, as well as claims that have yet to be submitted by the provider,” the MAC source tells Eli.

While the other MACs didn’t respond to a request for information on Round 2, Probe & Educate review appears to be ongoing in the rest of the country. “We continue to see claims being selected for review in the non-PCR states,” reports billing expert M. Aaron Little with BKD in Springfield, Mo. After the conclusion of Probe & Educate Round 1, MAC CGS revealed to Eli it fully or partially denied 60 percent of the claims reviewed in the initiative, while Palmetto reported it denied 63 percent — all but 2.6 percent full denials. National Government Services did not release its P&E denial stats.

Whether those denial rates will increase or decrease under Round 2 is debatable.

On one hand: In Illinois, denial rates will hopefully improve “given all the ‘opportunities’ providers in that state have had to work on compliance in the PCR process,” Little says.

On the other hand: Round 2 is eliminating Round 1’s top performers, so average denial rates may rise accordingly.

A recent Government Accountability Office report focusing, in part, on Medicare’s P&E initiative notes that CMS hasn’t set performance metrics for the hospital or home health P&E campaigns. “Because providers billing properly were removed after each round, [CMS] could not determine how much the overall denial rate effectively decreased from the first to third rounds, noting that the decrease in the claims denial rate could be greater than results indicated,” the GAO says of Medicare’s hospital P&E project.

“It is too early to say whether the home health probe and educate reviews are successful because only one round of reviews had been completed at the time of our review,” the GAO judges.

“The probe and educate reviews are resource-intensive,” the GAO adds in the report released April 10. “Though their costs have not been quantified by CMS, the reviews require manual assessments of thousands of claims, as well as the offer of one-to-one education from the MACs to certain providers.” Due to the program’s costly nature, CMS needs to implement benchmarks to determine whether the campaign is actually reducing improper payments, the GAO urges in the report.