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Denial rates over 25% will keep you on TPE review at this MAC.<\/em><\/strong><\/span><\/p>\n The results from the first wave of Targeted Probe & Educate are rolling in, and they point to medical review \u2014 and thus reimbursement \u2014 trouble ahead.<\/p>\n According to HHH Medicare Administrative Contractor\u00a0CGS<\/strong>, 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 \u201ccompliant,\u201d the MAC says in a new post to its website summarizing its TPE results for the first six months.<\/p>\n 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 \u201cthrough data analysis demonstrating high risk for improper payment,\u201d the MAC says, although it doesn\u2019t go into further detail on what constitutes that high risk.<\/p>\n Of those 15, CGS found only three agencies to be \u201ccompliant after round 1 completion\u201d and 12 to be \u201cnon-compliant after round 1 completion.\u201d That means four-fifths of the agencies will be staying on TPE for round 2, requiring another 20 to 40 ADRs, explains\u00a0Joe Osentoski<\/strong>, reimbursement recovery & appeals director for\u00a0QIRT\u00a0<\/strong>in Troy, Michigan.<\/p>\n The 80 percent denial rate compares to a 60 percent denial rate by CGS in the first round of TPE\u2019s predecessor, Probe & Educate, and a 63 percent denial rate by MAC\u00a0Palmetto GBA\u00a0<\/strong>in the first P&E round. But remember, MACs reviewed five claims from every HHA in the nation for P&E round 1, rather than targeting high-risk providers.<\/p>\n 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.\u00a0National Government Services\u00a0<\/strong>didn\u2019t release its P&E denial stats.<\/p>\n F2F Problems Dog HHAs<\/strong><\/span><\/p>\n CGS lists the top five causes for denials under TPE, which make up 65 percent of the reasons\u00a0(see box, p. 155, for reasons and details<\/em>). Topping the list by far is the physician face-to-face encounter at 30 percent.<\/p>\n It\u2019s no surprise F2F tops the chart, notes reimbursement expert\u00a0M. Aaron Little\u00a0<\/strong>with\u00a0BKD\u00a0<\/strong>in Springfield, Missouri. The requirement has been giving HHAs major headaches since its inception and is \u201cone of the most common problems we continue to see,\u201d Little says.<\/p>\n The unexpected part is that F2F made up only 30 percent of the denials, Osentoski says.<\/p>\n \u201cThis denial percentage actually seems low compared to prior review results,\u201d he points out. For example, for P&E round 1, CGS said\u00a0<\/strong>that nearly 52 percent of the claims it denied were due to a missing, incomplete or invalid F2F.<\/p>\n Pitfall:\u00a0<\/strong>\u201cSome 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,\u201d notes consultant\u00a0J\u2019non Griffin<\/strong>, owner of\u00a0Home Health Solutions\u00a0<\/strong>in Carbon Hill, Alabama.<\/p>\n Remember, under rules that were finalized in the 2015 Home Health Prospective Payment System final rule and took effect Jan. 1, 2015, the\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>scrapped the much-hated physician narrative requirement for F2F. Instead, however, a physician\u2019s own record must substantiate the patient\u2019s home care eligibility \u2014 and\u00a0agencies must obtain and then submit\u00a0<\/em>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.<\/p>\n Is F2F Hiding Therapy Documentation Shortfalls?<\/strong><\/span><\/p>\n The number-two denial reason for CGS under TPE, also by a wide margin at 18 percent, is \u201cdocumentation did not support medical necessity of therapy services,\u201d the MAC reports on its website. This one isn\u2019t exactly a shocker either.<\/p>\n \u201cI often see the medical necessity of this not being documented,\u201d Griffin says. CGS had reported this reason as accounting for 7 percent of denials under P&E round 1.<\/p>\n It\u2019s \u201cnot really a surprise that they have finally started having higher denial rates because of the therapy,\u201d Griffin says. \u201cTherapists have historically not been challenged by administration if they say a patient needs more therapy, often because nurses didn\u2019t understand enough about what therapists did challenge them.\u201d<\/p>\n Don\u2019t 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. \u201cAs we start moving toward therapy not being the main basis for increased reimbursement,\u201d watch for therapy utilization to decline, she expects.<\/p>\n Also:<\/span>\u00a0<\/strong>The new Home Health Conditions of Participation that took effect in January \u201crequire the clinical manager to be knowledgeable of all aspects of care,\u201d Griffin adds. That may lead to closer supervision and control of therapy utilization as well.<\/p>\n HHAs may actually see therapy-based denials increase, however. That\u2019s because currently, \u201cmany therapy denials may be masked because the claim is denied due to an invalid face-to-face encounter,\u201d Osentoski points out.<\/p>\n As HHAs improve their F2F documentation under TPE, more therapy problems may emerge.<\/p>\n Note: See CGS\u2019s TPE results at\u00a0www.cgsmedicare.com\/hhh\/pubs\/news\/2018\/0518\/cope7655.html<\/a>.\u00a0<\/em><\/p>\n Source- SuperCoder<\/span><\/i><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"