Home Health & Hospice Week

Nearly all HHAs fail medical review again.

Another quarter brings another round of dismal Targeted Probe and Educate results from HHH Medicare Administrative Contractor CGS.

In the quarter ended Dec. 31, 2018, CGS reviewers completed 76 TPE round 1 reviews. They found only two home health agencies “compliant” in the reviews, advancing 74 agencies on to round 2, says a new post on the MAC’s website. That’s a 97.4 percent failure rate.

Fifty-five of the probes were for the Eligibility and Medical Necessity edit (5A000), CGS says. The two compliant findings occurred for this probe.

Twenty-one of the probes were for the No response to Additional Development Request edit (5A004), CGS says. There were no compliant findings for that edit.

The 97.4 percent failure rate does compare favorably to the rate CGS reported for the previous quarter, which was more than 99 percent (see Eli’sHCW, Vol. XXVII, No. 43). But not by much.

New: For the first time, CGS also posts findings for round 2 edits. In the three round 2 probes CGS completed in the quarter, reviewers found all three agencies noncompliant.

Is TPE MAC Education Falling Short?

The continued terrible results suggest that CGS “is doing a good job with the ‘targeted’ part of TPE and less so with the ‘educate’ portion,” says Joe Osentoski, Reimbursement Recovery & Appeals Director with Quality in Real Time in Troy, Michigan.

When CGS reported results for the first two quarters of TPE, Oct. 1, 2017 through March 31, 2018, about 20 percent of agencies were found “compliant” and 80 percent went on to round 2 (see Eli’s HCW, Vol. XXVII, No. 20). That 20 percent compares to a tiny 0.65 percent and 2.6 percent success rate in the two most recent quarters.

The MAC seems able to zero in on agencies that are less likely to respond to ADRs, or whose documentation won’t withstand scrutiny, the latest results imply.

CGS reports that 14 of 55 agencies included for the Medical Necessity edit 5A000 did not even respond, or did not fully respond, to the TPE ADR requests. That fact “supports that they were appropriately targeted,” Osentoski surmises.

“There is no excuse for non-response to ADRs,” Osentoski stresses. “CGS has made substantial information available on how to identify ADRs, a written letter is provided to the agency when placed on a TPE review, and the ADR document itself is a relatively easy document to follow.”

The same pattern of nonresponse “also holds true for the nine of 21 agencies specifically targeted due to their prior Probe & Educate nonresponses that still did not respond to their TPE ADRs,” Osentoski points out.

Bottom line: “Non-response guarantees denials and are of no help to alter the perception of home health waste, fraud, and abuse that is the primary basis for TPE reviews,” Osentoski says.

When agencies do respond to the TPE ADRs, the denials for technical reasons are also frustrating, Osentoski says (see related story, below).

And if the education were working, HHAs would improve between stages of round 1 TPE, and would improve in round 2 TPE. If the MAC education provided after round 1 was effective, “at least some of these agencies should have been found compliant with round 2,” Osentoski says. But all of them failed.

“If the education provided after round 2 is the same as after round 1, that can point towards ineffective delivery of that key information as much as the agency not following it appropriately,” Osentoski maintains.

Of course, targeted agencies may have systemic problems that are too “embedded” to overcome, he allows.

Don’t forget: Failing round 3 will lead to “penalties and drastic actions,” Osentoski warns.

“Any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps,” the Centers for Medicare & Medicaid Services warns on its TPE website. “These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”

Note: CGS’s results are at www.cgsmedicare.com/hhh/pubs/news/2019/0119/cope11067.html.