Home Health & Hospice Week

You’ve seen the top denial reasons, now look at the rest.

Santa shouldn’t be the only one who is checking his list twice this holiday season.

The two Home Health & Hospice Medical Administrative Contractors that serve the majority of the nation’s home health agencies recently revealed their failure rate for agencies undergoing Targeted Probe and Educate medical review, and the results were concerning. MAC CGS reported its reviewers found a startling 99 percent of reviewed agencies noncompliant in round 1 during the most recent period, while Palmetto GBA’s reviewers found a still substantial 54 percent noncompliant. (See Eli’s HCW, Vol. XXVII, Nos. 43 and 44 for more details of the MACs’ recent TPE results.)

Reminder: When a MAC finds an agency noncompliant in round 1, it moves on to round 2 of TPE. If an HHA fails round 2, it will move on to round 3 of TPE. If it still doesn’t shape up, “providers/suppliers with continued high error rates after three rounds of TPE may be referred to [the Centers for Medicare & Medicaid Services] for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action,” CMS says on its website.

Both MACs issued top TPE denial reason lists as well, with both featuring face-to-face physician encounter reasons as the top problem. However, both contractors listed only the five most common reasons. That accounted for about two-thirds of TPE denial reasons, leaving the other third a mystery.

Now, CGS has provided a more exhaustive list of TPE denial reasons to Eli. Check out the other reasons keeping HHAs under the TPE microscope:

1. Plan of care missing/invalid, 7 percent
2. Skilled nursing not medically necessary,
3. percent
4. Orders not signed timely, 3 percent
5. Documentation does not support home bound, 3 percent
6. Plan of care signed but untimely, 3 percent
7. OASIS not supported/downcode, 3 percent
8. Plan of care signed but not dated, 2 percent
9. Plan of Care/Certification not signed, 2 percent
10. No orders or exceeded orders, 2 percent.

Being able to see a more comprehensive list of denial reasons is helpful, experts say. “I think the percentage numbers are reasonable and in line with our providers,” notes Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas.

But problems remain with the denial list. The vagueness of some of the reasons is confusing, maintains reimbursement expert M. Aaron Little with BKD in Springfield, Missouri.

For example: With “Plan of care missing/invalid,” which account for 7 percent of CGS’s TPE denials, “was the POC missing or was it invalid because those are not the same or similar reasons to deny a claim?” Little asks. “What does ‘invalid’ mean when there is a separate reason for ‘signed but not dated,’ ‘not signed,’ and ‘signed but untimely?’”

Details about the data calculations are likewise still fuzzy, Olson observes. For instance, what exactly comprises the denominator for the percentage figures?

Plus: CGS’s list still leaves 5 percent of denials unaccounted for, points out Joe Osentoski, reimbursement recovery and appeals director with Quality In Real Time in Troy, Michigan.

Providers also should keep in mind that the TPE denial list will evolve, emphasizes a representative for Palmetto GBA. “As providers improve the medical documentation to support the home health services, the top 5 denial reasons will change,” the rep explains.

Learn These Lessons From Denial Reasons

Agencies should note that “the total reported percentage of non-administrative denials only constitutes 5 percent” with the skilled nursing medical necessity reason, Osentoski highlights. Or perhaps “8 percent if you add in not homebound,” he allows.

“Due to medical review hierarchy, this makes sense since the plan of care, certification, and orders are looked at prior to proceeding with review of medical necessity,” Osentoski explains. “However, it reinforces the critical need for agency action to remove these issues via robust documentation flow processes: review of face-to-face encounter at time of admission, validating all components of certification are present, checking all physician orders are signed and dated, and that all medical record requests have responses,” he urges.

Bottom line: The expanded list of denial reasons shows that “agencies are handing back money by continuing ineffective referral, plan of care generation, and real-time quality assurance reviews prior to submission of the final bill,” Osentoski warns.