What’s the Latest Home Health ADR & Denial Buzz?

Posted on Thursday, June 15, 2017 8:02 PM

Effective April 2017, CMS began to enforce the requirement that OASIS documents must be submitted within 30 days. While this rule has been in place, it is now being enforced and agencies are receiving this type of denial notice.

If you submit the final claim and there is no OASIS in the QIES (Quality Improvement Evaluation System) within the 30-day timeframe, the claim will be denied.

However, agencies are reporting that there may be glitches to this process because in some cases they do have validation that they submitted their OASIS within the 30-day timeframe. If you have your validation report showing that you submitted the OASIS timely, then it needs to be sent with your reconsideration request. A reminder that the response timeframe for this denial is much tighter than a typical ADR.

Some agencies have reported that they note a higher number of denials if they have modified their OASIS and then resubmitted it.

When submitting your OASIS, ensure staff are responding to fatal errors and warnings received during the QIE submission process, so that you are addressing any timing issues to avoid receiving a denial.

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CMS Probe Edits-Round 2

The Centers for Medicare & Medicaid Services (CMS), are conducting Round 2 of their Home Health Probe & Educate medical review strategy. Exciting news for those agencies who had minimal errors in Round 1, they will not receive Round 2 probe edits!

Similar to Round 1, agencies will receive requests for additional documentation for five records. The Round 2 probe edits will be reviewing claims for valid Face-to-Face encounter documentation, medical necessity, coverage guidelines, correct billing and coding.

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Top ADR Denial Reasons

In reviewing the Palmetto Top Denial Reasons Jan-March 2017, it is of note that the top reason for denial (44%) relates to agencies not responding to ADR requests in a timely manner. Of all the denial reasons, this is the easiest one to address. Take the time within your agency to define who in your agency is responsible for pulling the additional documentation requests, the process for review of the documentation prior to sending it, the process for responding to the requests, and a tracking system to manage due dates. If all of this is not clearly defined in your agency, there are many potential process gaps that can impact your responding to the ADR timely and appropriately.

The second and third top reasons for denial were Face to Face Encounter not meeting the requirements and HIPPS code change due to partial denial of therapy.

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If you are having challenges with ADR’s, Consider Corridor for expert support for the management of your ADRs to ensure timely, accurate submissions!

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Written by Sue Payne, Corridor’s Vice President of Clinical Services & Innovation.

About Corridor

Corridor is the nation’s preferred partner and trusted business advisor to home health and hospice providers, providing quality services and impactful results for 30 years. Focusing on key operational, regulatory and financial challenges, Corridor delivering industry-unique solutions and deep expertise in coding, clinical documentation review, compliance, billing and collections , consulting and provider staff education . At Corridor, we make the business of caring for people Better! For the most important industry updates and news that impacts home health and hospice, please make sure to sign up for our weekly newsletter to receive the latest up-to-date industry information direct to your inbox!

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