The second round of probe-and-educate reviews is getting underway, with home health agencies in Florida the first to be affected.
The first additional document requests (ADRs) will be sent to Florida agencies on or around Dec. 27, according to Medicare Administrative Contractor (MAC) Palmetto GBA. As in the first round of probe-and-educate, the MAC will do pre-payment review of a sample of five claims.
Agencies that had five claims reviewed in the first round and had one or zero claim in error will be excluded from this round. All other agencies should expect to receive a probe-and-educate request, Lynn Labarta, founder and CEO of Imark Consulting, told Home Health Care News.
CMS has not specified which states will follow Florida in this second probe-and-educate round, although Texas is a likely possibility, Labarta added.
As they did in the first round, the MAC reviewers will be looking at the claims to ensure that agencies are in compliance with Medicare eligibility and payment requirements.
In Florida, for claims that are denied or partially denied after being reviewed, the MAC auditor will contact the home health agency by phone on the day that the review takes place, according to Palmetto.
“If during a call with a nurse reviewer about a denied service, it is determined the ADR response was incorrectly denied, the provider does not need to request a redetermination. The review contractor will reopen the claim and make the change to the claim,” a Palmetto GBA spokesperson told Home Health Care News. “A corrected decision letter will be sent to reflect the change. However, if it was determined during that call that the claim was denied because something was missing or incorrect with the documentation, the provider will need to request a redetermination.”
Depending on the number of errors detected, the MAC will take different follow-up actions, as outlined in a Dec. 16 Medicare Learning Network memorandum from the Centers for Medicare & Medicaid Services (CMS):
The MACs’ follow-up letters for denied claims were pretty specific in the first round, Labarta said, and the majority of issues for Imark clients involved face-to-face.
Flagging the face-to-face documents and other important documents, such as specific orders for therapy and progress notes, is one best practice for agencies in submitting their ADRs, according to Labarta.
It’s also a good idea to include an outline so that the reviewers know where in the submission to look for various items.
“Sometimes the reviewers miss documentation they’re looking for,” Labarta said. “An outline helps, so the reviewer doesn’t turn around and say, the face-to-face isn’t there.”
Another tip she shared: request a return receipt if mailing the documents to the MAC, rather than submitting them electronically.
While agencies may have a relatively short timeframe to respond to the document requests, and taking these extra steps adds to the burden, it is worthwhile to avoid being dinged for errors and having to do a second-level appeal in order to get paid, she emphasized.
Written by Tim Mullaney