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Need Help? Second Round Of Probe And Educate Review Is Here!

Late last year, Centers for Medicare & Medicaid Services (CMS) announced the roll out of the Home Health (HH) Probe and Educate Review Program. Each Medicare Administrative Contractor (MAC) conducts these reviews. This round required all Medicare HH agencies (HHAs) to submit five Additional Documentation Requests (ADRs) for prepayment review. According to first round data, 92% of the HHAs received payment denials on at least one but up to five of these ADRs. CMS considers the results of this review a colossal agency failure. As a result, in January 2016, CMS released additional information about the failed ADRs. And based on the outcomes of the initial five ADRs, CMS requested additional records for review.

Fast forward to 2017. Currently, the second round of  HH Probe and Educate Reviews are underway with agencies in Florida the first to experience these reviews. According to the MAC Palmetto GBA, as in the first round, MACs will do a pre-payment review of a five claim sample. However, agencies with claim reviews in the first round with only one or zero claim errors will not receive reviews in round two. Therefore, all other home health agencies should expect to receive a probe-and-educate review request.

Probe and Educate Review

What is a Probe and Educate Review?

Throughout this document, the term “HH Probe and Educate Review” will refer to home health reviews conducted by each MAC. These reviews will determine if the requirements for HH certification/recertification, patient eligibility, coding and medical necessity (CMS-1611-F requirements) meet compliance.

Purpose of the Home Health Probe and Educate Review

The primary HH Probe and Educate review process purpose is to ensure understanding of the patient certification CMS-1161-F requirements. CMS will direct MACs to apply CMS-1611-F and any additional CMS guidance, when conducting HH Probe and Educate reviews. Eligible claims will be for HHA episodes that start on or after August 1, 2015.

During the second round of reviews, MACs will take different follow-up actions, depending on the number of errors found in each review.  See the December 16, 2016 CMS Medicare Learning Network memorandum to examine these actions.

When conducting a HH Probe and Educate review, CMS will instruct MACs to review the 5 sample claims for compliance with:

  • Certification/recertification documentation of patient eligibility for Medicare home health services
  • Face-to-face encounter requirements
  • Coding
  • Medical necessity
  • Medicare coverage and payment criteria

Areas Subject To Additional Documentation Requests

While the program’s intent is to educate home health providers, those with significant deficiencies may be subject to further reviews and additional documentation requests. During round one the most common denials involved face-to-face issues.

Particular review and scrutiny areas for the latest reviews will focus on:

  • Excessive lengths of stay (120 to over 300 days average LOS)
  • Questionable patient eligibility and medical necessity
  • Failure to obtain required face to face documentation for all cases
  • Coding that does not have supporting documentation as to severity

More Probe and Educate Review Information

CMS modified the additional documentation request (ADR) limits for the Recovery Auditor program for home health providers effective January 1, 2016. Therefore, HHAs may expect an increase in ADRs.  Consider the following CMS instructions and information.

Additional Documentation Limits for Medicare providers (except suppliers and physicians)

CMS is basing each provider’s annual ADR limit on the number of Medicare claims paid in the previous year associated with their 6-digit CMS Certification Number (CNN) and the provider’s National Provider Identifier (NPI) number.

  1. The annual ADR Limit will be one-half of one percent (0.5%) of the provider’s total number of paid Medicare claims from the previous year.
  1. CMS is sending ADR letters on a 45-day cycle. The annual ADR Limit will be divided by eight to establish the ADR cycle limit, which is the maximum number of claims that can be included in a single 45-day period. Although the Recovery Auditors may go more than 45 days between record requests, in no case shall they make requests more frequently than every 45 days.

For example:

  • Provider A billed and was paid for 22,530 Medicare claims in 2014. The provider’s ADR limit would be 22,530 x 0.005, which is 112.65. The ADR cycle limit would be 112.65/ 8 = 14.08 and would be rounded to 14 additional documentation requests per 45 days.
  • Provider B billed and was paid for 255,000 Medicare claims in 2014. The provider’s ADR limit would be 255,000 x 0.005, which is 1,276. The ADR cycle limit would be 1,276/ 8, which is 159.375 and would be rounded to 159 additional documentation requests per 45 days.
  1. ADR limits will be diversified across all claim types, based on the Types of Bill (TOB) that the provider was paid for in the previous year.
  1. CMS will adjust a provider’s ADR limit based on the provider’s compliance with Medicare rules. Providers with low denial rates will have ADR limits decrease. And conversely, providers with high denial rates will see their ADR limits increase.
  1. CMS reserves the right to establish a different record limit when directing the Recovery Auditors to conduct reviews of specific topics or providers.
  2. Additionally, direct questions concerning this update to RAC@cms.hhs.gov.

Hence, Kenyon HomeCare Consulting believes that agencies must prepare for the continual increase in prepayment ADRs. Also, you must have the ability to contest as many denials as possible. Failure to either successfully contest denials or to not have the standing to contest, may well put you out of business.

If you are struggling with ADRs or round two of Probe and Educate Reviews, we are here to help! Call 206-721-5091 or contact us to schedule an appointment to get assistance today.

Category: Education & Training, ICD Coding, Leadership

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