Home Health & Hospice Week

Major discrepancy between MACs shows in results.

If you consider a 50 percent failure rate to be not so bad in medical review terms, then Palmetto GBA’s newly released Targeted Probe and Educate results look promising.

The HHH Medicare Administrative Contractor processed 552 round 1 probes from Oct. 1, 2017 through Sept. 30, 2018, Palmetto notes on a TPE results article posted on its website. Of those, the MAC found 300 home health agencies (54 percent) “non-compliant,” sending them on to round 2 TPE review. Reviewers found 252 (46 percent) “compliant,” dropping them off TPE.

Palmetto’s results may sound dismal — until you compare them to the ones released by HHH MAC CGS. In the latest time period, July 1 to Sept. 30, 2018, CGS found only one out of 152 home health agencies complaint, sending the rest (more than 99 percent) on to round 2 (see Eli’s HCW, Vol. XXVII, No. 43). Earlier this year, CGS reported from Oct. 1, 2017 through March 31, 2018, its reviewers found about 20 percent of agencies “compliant” and 80 percent went on to round 2.

The MACs’ risk category findings follow suit. Palmetto breaks out its categories into “minor” (error rate 0 to 20 percent) and “major (21 percent and up). From October 2017 through September 2018, 54 percent were major and 46 percent minor.

In contrast: CGS places agencies into three categories: “significant” (error rate greater than 50 percent); “moderate” (26 to 50 percent); and “minor” (error rate 0 to 25 percent). From July 1, 2018, to Sept. 30, 85 percent of agencies fell in the “significant” category, 14 percent in the “moderate” category, and 1 percent in the “minor” category. The earlier time period from Oct. 1, 2017, to Sept. 30, 2018, saw 79 percent of agencies reviewed falling into the significant category, 18 percent moderate, and 3 percent minor.

Experts are at a loss as to why the TPE results are so different between the MACs, especially when denial reasons are so similar (see story, this page). A best case scenario could be that “perhaps CGS is more refined in their ability to identify billing aberrancies that are then validated by their high noncompliance rate,” offers Reimbursement Recovery & Appeals Director Joe Osentoski with QIRT in Troy, Michigan. In other words, “are they just better at finding the at-risk agencies and then proving them as such with the actual review?” Osentoski asks.

Keep in mind that the TPE jury is far from in. In its review, Palmetto breaks out results by state, recording no reviews in high-density states such as Florida and Illinois. That could be due to Pre-Claim Review/Review Choice Demonstration duplication considerations, experts suggest. Other states known for high denial rates in review, such as Louisiana, Alabama, and Mississippi, also are noticeably missing from the results and may change the ratios if and when they are included.

Note: See Palmetto’s TPE results at www.palmettogba.com/palmetto/providers.nsf/vMasterDID/B6YPUS7372 and CGS’s at www.cgsmedicare.com/hhh/pubs/news/2018/1118/cope10075.html.