Home Health & Hospice Week

Make sure you're prepared to defend claims for long-stay hypertension patients.

The data crunching the MACs are doing to identify Targeted Probe & Educate targets seems to still be under wraps, but one contractor has revealed the home health topics it is pursuing under the program.

According to its most recent website update, HHH Medicare Administrative Contractor CGS says these TPE edits are currently in place for home health agencies:

Home Health Eligibility and Medical Necessity: selects providers who submitted home health claims with errors as identified in HH probe and educate round 2.

"They are focusing on providers who did not do well in the second round of Face-to-Face probe and educate," says attorney Robert Markette Jr. with Hall Render in Indianapolis. "That is not a huge surprise, because they indicated that the second round went so poorly they were considering third round." Agencies that performed poorly on the second round will likely see further audits resulting in additional recoveries, Markette cautions.

Unfair: MACs, of course, won't acknowledge providers' protests that the F2F regulations are unreasonable and even impossible to meet. "I would say that F2F is really not that important and this is a blatant effort to recoup money for care that was legitimately provided," Markette charges.

No response to ADR: selects providers who fail to respond to Additional Development Requests. This topic seems "to be geared at 'low hanging fruit,'" Markette believes. "If you didn't respond before and the MAC took your money, they can come back around and potentially have another easy recoupment when you don't respond the second time," he reasons. "There may be more to it than that, but it wouldn't surprise me if that was the logic."

Of course, if the volume of nonresponses "was high enough, it could indicate a provider individual problem, so it would be a worthwhile probe," judges clinical consultant Pam Warmack with Clinic Connections in Ruston, Louisiana.

Some providers just don't respond to ADRs if they know the claim will get denied anyway. Under this policy, agencies should likely reconsider that practice. (For tips on curbing a higher ADR nonresponse rate, see Eli's HCW, Vol. XXVI, No. 35.)

LOS with Hypertension: selects home health claims for providers that submitted diagnosis Hypertension and a length of stay greater than 120 days.

This topic isn't surprising, since "LOS and chronic illnesses with recertifications is a likely target," Warmack says.

This topic seems to target patients who may not be eligible, Markette says. "They have ... expressed concerns about hypertension in the past."

Note: See CGS's TPE topic list at www.cgsmedicare.com/hhh/medreview/activitylog.html.