Only 5% of Agencies Passed Round 1 of CGS’ Review

Posted on Thursday, January 19, 2017 3:21 PM

During the first round of CMS’ probe-and-educate review, a majority of home health agencies failed. An announcement was made at the end of 2016 that these agencies will be faced with a second round, according new data from the Medicare Administrative Contractors (MACs) show.

Only 5% of agencies in CGS’ area will be exempt from Round 2.

According to Palmetto, only 15.1% of providers with Palmetto GBA as their MAC will be exempt from the second round. Palmetto’s figures exclude Illinois agencies.

After viewing the probe’s results, “Someone has to see that is a sign of a terrible regulation, not agency incompetence,” contends attorney Robert Markette of Indianapolis-based Hall, Render, Killian, Heath & Lyman. “There is too much riding on physician compliance, which we cannot control.”

Round 2 of the review began in late 2016 and will end in about a year, CMS said in MLN Matters article SE1635.

Agencies with two to five claims in error during the probe’s first round will receive five more additional documentation requests (ADRs) from MACs (HHL 1/2/17).

In Round 1, Palmetto fully or partially denied a total of 62.6% of claims. In the review’s first round, 71.2% of CGS’ claims were either fully or partially denied.

Nearly two-thirds of denials were due to face-to-face documentation issues. The issues include:
• Actual face-to-face encounter document not submitted
• Certifying physician did not document the date of the face-to-face encounter
• Community physician was not identified when a physician who would not be following the patient after discharge signed the certification
• Estimated length of skilled services was not documented in the recertification document
• Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification

23% of CGS’ denials occurred due to agencies not responding to ADRs.

Agencies need to make sure they have a process in place to identify and respond to ADRs — they “should never lose money simply because they did not respond,” Markette says.

Agencies who passed Round 1 and are exempt from Round 2 offered the following advice to HHL about how to avoid getting denials during the review:
• Number your pages and create an index when responding to ADRs
• Have multiple people check what you submit
• Read instructions very closely
• Embrace technology
• Close the loop
• Set up a process to ensure the ADR won’t get lost in the shuffle
• Take a different approach when educating physicians
• Audit, audit, audit

For the full article, please see the January 23, 2017 Home Health Line Edition.

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