Home Health & Hospice Week

Plan of Care denials top Palmetto GBA's list.

Another HHH MAC has released preliminary Targeted Probe & Educate review results, and they again bode ill for home health agencies.

HHH MAC CGS recently issued TPE results indicating that its reviewers found only 20 percent of HHAs that completed TPE round 1 review "compliant," and thus able to get off the program, in TPE's first six months (see Eli's HCW, Vol. XXVII, No. 20). That compares to 5 percent of HHAs found compliant under Probe & Educate round 1 for CGS and 15 percent for Palmetto GBA (see Eli's HCW, Vol. XXVI, No. 31).

Now, HHH MAC Palmetto GBA has released TPE stats to Eli. Instead of releasing figures on how many providers "passed" TPE, Palmetto

says that its reviewers have denied (either partially or fully) 30.7 percent of the claims they have examined under the program thus far. In other words, the MAC denied 1,671 claims out of 5,442 reviewed.

Palmetto has also divulged that 217 of the 2,131 HHAs targeted under TPE have completed round 1 of the program as of May 23, a MAC spokesperson says. That's a far larger number than the 15 agencies that completed TPE round 1 by March 31 at CGS.

Unlike CGS, Palmetto did not reveal its error rate cut-off point for getting off TPE. CGS said its was 25 percent.

Palmetto has released the top denial reasons under TPE, although it hasn't quantified them. They are, in order:

• no plan of care or certification,
• no physician order for services or more than ordered,
• face-to-face encounter requirements not met, and
• no documentation of services rendered.

Stay tuned: "Palmetto GBA will publish the results of round 1 once all providers have completed round 1," the Palmetto spokesperson tells Eli. The results will "include charge denial rate and top granular denials to include education to avoid these errors in the future."

F2F Lower On Denial List Than Expected

Palmetto's top denial reasons aren't a surprise, says reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. Most of them also showed up in CGS's list.

What is a little unexpected is that F2F is the number-three reason, rather than one or two, notes Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan. "This is actually a hopeful sign that it is not the top denial reason," Osentoski says. Of course, some of the F2Frelated denials might also be grouped in with the other categories, he cautions - it will be hard to tell until Palmetto issues its granular denial details.

Osentoski suspects that the "no order denial reason is mostly missing recertification estimates by the physician," he adds.