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Staying on the Offense; HH Targeted Probe and Educate Reviews

Posted on Wednesday, September 20, 2017 9:21 PM

Now that CMS has noticed a decrease in home health claim errors based on their Probe & Educate review approach, the home health industry can anticipate more of the same.

In 2016, CMS requested Round 1 Probe & Educate record reviews (5) per home health provider. Based on those initial reviews, CMS then initiated a Round 2 Probe & Educate record reviews (5) per home health provider unless you were a provider with a zero or one claim only during Round 1.

As the Round 2 reviews wrap up in September, CMS will now begin a focused approach for those agencies with high denial rates. For these providers, the HH TPE requests will be for 20-40 claims per round which can be repeated up to three rounds. CMS is pairing its’ probe approach with provider guidance to decrease errors, so agencies will receive specific education based on the error results. The goal is to identify errors and educate so that the agencies can avoid these errors in the future.

One word of caution if you do continue to have high error rates, CMS may refer the agency to Recovery Audit Contractor, place the agency on pre-pay reviews, and/or use extrapolation to determine agency penalties. 

The focus of the Probe & Educate reviews continues to be related to Face-to-Face Encounter documentation, home bound status, skilled need, and certification requirements.

What should agencies be doing to stay on the offense?

  • Ensure that ADR requests are identified timely by routinely checking to see if there are requests
  • Ensure that your agency is responding within the required time frame (this is low hanging fruit and is one of the top reasons for denials)
  • When recertifying patients, include a projected date of how long the patient will be on service
  • Utilize an administrative resource to track when the agency receives ADR requests, to do technical review for completeness prior to sending additional documentation, and to ensure deadlines are being met for ADR response
  • Utilize an administrative resource in real time to review all Face to Face encounter information has the required information, dates, and physician signature
  • Utilize an outsourcing company to do a sampling of documentation reviews related to the Probe & Educate areas of focus such as compliance with Face to Face Encounter, homebound, skilled need, and recertification requirements

 

Written by Sue Payne MBA, RN, CHCE, Vice President of Clinical Services & Innovation at Corridor

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