Home Health & Hospice Week

Denial rates over 25% will keep you on TPE review at this MAC.

The results from the first wave of Targeted Probe & Educate are rolling in, and they point to medical review - and thus reimbursement - trouble ahead.

According to HHH Medicare Administrative Contractor CGS, reviewers found a mere 20 percent of the home health agencies it reviewed under the TPE program from Oct. 1, 2017, to March 31, 2018, to be "compliant," the MAC says in a new post to its website summarizing its TPE results for the first six months.

CGS completed Round 1 of TPE review for only 15 HHAs across 10 states in that six-month period, it notes on its website. CGS chose agencies for complex medical review under TPE "through data analysis demonstrating high risk for improper payment," the MAC says, although it doesn't go into further detail on what constitutes that high risk.

Of those 15, CGS found only three agencies to be "compliant after round 1 completion" and 12 to be "non-compliant after round 1 completion." That means four-fifths of the agencies will be staying on TPE for round 2, requiring another 20 to 40 ADRs, explains Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan.

The 80 percent denial rate compares to a 60 percent denial rate by CGS in the first round of TPE's predecessor, Probe & Educate, and a 63 percent denial rate by MAC Palmetto GBA in the first P&E round (see Eli's HCW, Vol. XXVI, No. 3). But remember, MACs reviewed five claims from every HHA in the nation for P&E round 1, rather than targeting high-risk providers.

The 80 percent TPE denial rate compares to a 67 percent denial rate when CGS ran P&E round 2, which consisted of providers that had two or more claims with errors in P&E round 1 (see Eli's HCW, Vol. XXVII, No. 6). National Government Services didn't release its P&E denial stats.

F2F Problems Dog HHAs

CGS lists the top five causes for denials under TPE, which make up 65 percent of the reasons (see box, p. 155, for reasons and details). Topping the list by far is the physician face-to-face encounter at 30 percent.

It's no surprise F2F tops the chart, notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. The requirement has been giving HHAs major headaches since its inception and is "one of the most common problems we continue to see," Little says.

The unexpected part is that F2F made up only 30 percent of the denials, Osentoski tells Eli.

"This denial percentage actually seems low compared to prior review results," he points out. For example, for P&E round 1, CGS told Eli that nearly 52 percent of the claims it denied were due to a missing, incomplete or invalid F2F (see Eli's HCW, Vol. XXV, No. 11).

Pitfall: "Some agencies are still trying to comply by using a form, and not putting the information on the plan of care with the required elements along, with a progress note for the patient," notes consultant J'non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

Remember, under rules that were finalized in the 2015 Home Health Prospective Payment System final rule and took effect Jan. 1, 2015, the Centers for Medicare & Medicaid Services scrapped the much-hated physician narrative requirement for F2F. Instead, however, a physician's own record must substantiate the patient's home care eligibility - and agencies must obtain and then submit those records for medical review when they receive an Additional Development Request. One saving grace is that the physician can sign agency-furnished documentation into her own record.

Is F2F Hiding Therapy Documentation Shortfalls?

The number-two denial reason for CGS under TPE, also by a wide margin at 18 percent, is "documentation did not support medical necessity of therapy services," the MAC reports on its website. This one isn't exactly a shocker either.

"I often see the medical necessity of this not being documented," Griffin tells Eli. CGS had reported this reason as accounting for 7 percent of denials under P&E round 1.

It's "not really a surprise that they have finally started having higher denial rates because of the therapy," Griffin says. "Therapists have historically not been challenged by administration if they say a patient needs more therapy, often because nurses didn't understand enough about what therapists did challenge them."

Don't be amazed to see this figure change as the therapy landscape in home health changes, though, Griffin predicts. For one, the HH PPS reform plan mandated in the Bipartisan Budget Act of 2018 and expected in the 2019 proposed rule this summer must, by law, eliminate therapy as a case mix factor. "As we start moving toward therapy not being the main basis for increased reimbursement," watch for therapy utilization to decline, she expects.

Also: The new Home Health Conditions of Participation that took effect in January "require the clinical manager to be knowledgeable of all aspects of care," Griffin adds. That may lead to closer supervision and control of therapy utilization as well.

HHAs may actually see therapy-based denials increase, however. That's because currently, "many therapy denials may be masked because the claim is denied due to an invalid face-to-face encounter," Osentoski points out.

As HHAs improve their F2F documentation under TPE, more therapy problems may emerge.

Note: See CGS's TPE results at www.cgsmedicare.com/hhh/pubs/news/2018/0518/cope7655.html. For tips on protecting your agency from TPE review, see a future issue of Eli's Home Care Week.